Privileged to be Part of World’s Largest Vaccination Drive on 21 June 2021

KK's Vaccination Experience

Introduction

I went for my first vaccine shot yesterday (21 June 2021). Little did I knew that I would be amongst the first 2000 of the innoculatees on the Covin App (I am informed that there were 2000 vaccination centers that logged in the Covin App at 9 am. I was numero uno at Wockhardt Bombay Central Center) of the over 8.6 million citizens who were vaccinated yesterday. This is a world record of sorts. This blog is about two issues. First, my experience at such a world record shattering vaccination drive and second, my experience of the vaccine shot dispelling all the negative experience, misinformnation and bull shit (one politician has voiced his concern around the vaccine containing the serum of cow or calf. It would have been slightly better if it was a chimp) around the Covid vaccination experience that Indians have voiced on the social media.

The Largest Vaccination Drive in the World

Acting on Supreme Court of India’s directive, Covid Vaccination was made available to all citizens of India, above the age of 18, free of cost from yesterday by the Central Government. While the policy decision is being welcomed by all the States and some of the political parties, managing the strategy, co-ordination and logistics is a herculean task. I must congratulate all the teams involved in the State and Central Government for their world record shattering performance. Let me explain the magnitude. There are 137 countries in the world which have a population of less than 8.7 million. See Chart. Or in another words, a certain politician governing New Delhi who promised to vaccinate the whole of Delhi in 2 months provided vaccines are made available by the Center and a prescriber of odd/even rule, would have completed vaccinating all the males of Delhi in one day!

India's Vaccination Drive on 21 June 2021 — India’s Vaccination Drive on 21 June 2021

My Experience with the Vaccination Drive

As I had opted for Covaxin (see below) and was on the priority list of the Maharashtra Education and Drug Department (MEDD) of medical workers in February 2021. Due to my trip to Bangalore, I had to miss my slot. For four months, there was no supply of Covaxine first dose at their designated vaccination centers in Bombay. The slots which opened up in private hospitals filled up quickly. Hence after a wait of 4-months, I was able to get the booking for 21 June 2021. The Cowin App has its own issues and crashes as millions are simultaneously trying to book a slot across the country. There is similar issue at the vaccination centers early in the morning at 9 am when all the centers simultaneously log in to the Cowin site. After a few minutes, the site starts accepting the innoculatees information and the process begins. The rest of the process and protocols are smooth.

Why I went for Covaxin?

As I already had a Covid/SARS like infection in 2012 and the experience of all the doctors working for us with the Covaxin, I preferred to go for Covaxin instead of Covishield. The key differences between the two are given below:

Covishield vs Covaxin – As per Mohfw.gov.in

Covishield details

Intramuscular vaccine
Developer – Developed by the Oxford-AstraZeneca and manufactured by the Serum Institute of India (SII).
Vaccine type –
- Prepared using the viral vector platform
- Contains harmless chimpanzee adenovirus – ChAdOx1 incapable of infecting the receiver
- Teaches the immune system to prepare a defence mechanism against the active virus.
- Similar technology has been used for developing a vaccine against Ebola
- Doses required – Two-dose regimen
Efficacy – A good result of 81.3% efficacy rate, as per Medical News Today.

Covaxin details

Intramuscular vaccine
Developer – Developed by Hyderabad-based Bharat Biotech International Ltd in association with the Indian Council of Medical Research (ICMR) and the National Institute of Virology (NIV).
Vaccine Type –
- Inactivated vaccine
- Developed with Whole-Virion Inactivated Vero Cell-derived technology
- Containing inactive viruses, Covaxin teaches the immune system to prepare a defence mechanism against the active virus.
- Similar technology has been used for developing vaccines for various diseases like Seasonal influenza, Rabies, Polio and more.
Doses required – Two dose regimen
Efficacy – A good result of 80.6% efficacy rate, as per Medical News Today.

Post Vaccination Experience/Side Effects

As per the typical side effects mentioned for Covaxin, here is the summary of what I experienced

Injection site pain or swelling or redness or itching Stiffness in the upper arm Weakness in injection arm Body ache Headache Fever Malaise Weakness Rashes Nausea Vomiting	Yes No No No No No No No No No No
Others symptoms that I experienced	First urine after vaccine (2 hours later) was very brownish. Kidneys were cleaning up the mess

This morning I woke up as per my normal timing and even went for my daily walk (completed my 6000 steps target) https://www.linkedin.com/posts/kapilkhandelwal_beating-the-vaccine-jab-side-effects-to-the-activity-6812945231244333056-Qvxm I was in office today and worked through the day without any symptoms of any side effects (a slight head ache in the afternoon post lunch). It’s 12 midnight and I am still working on posting this blog.

Should Indian Government TikTok Twitter out?

Jack Dorsey in India 2018

Preamble

In November 2018, I attended a session with Jack Dorsey, the founder of Twitter organized by the ORF foundation at the Taj Lands End in Mumbai. During the session I vividly remember Jack Dorsey talking about his vision off Twitter has as a platform to provide the voice to the people of the world for better democracy and better governance of democracy. A strong, functional democracy relies upon the public’s access to high-quality information. However, the very next day, the social media was abuzz with a picture of Jack Dorsey demonstrating his hatred towards Hindu Brahmins. That’s not the beginning of Twitter’s bias to a certain religion in India. Raheel Khursheed who headed Twitter in India till 2018 also drew some backlash from several groups, who accused him of having associations with Kashmiri separatists, and were upset over Khursheed’s criticism of democratically elected PM of India Narendra Modi’s for his leadership and scraping unethical status of Kashmir. He is formally accused of not being neutral and fit for the job by blocking accounts of prominent Indians. During his tenure he had issued blue ticks to several prominent people of the anti-national Azad Kashmir Movement.

However we have seen the words and actions of Twitter not only during the election off 2019 but also after that. It seems that Jack Dorsey’s agenda in India is suspect and he does not walk his talk. The recent lock loggerheads with the Indian government and Twitter seems to indicate that Twitter itself is perpetrating religious hatred and other vicious political agenda in India. At the recent Parliamentary Committee meeting with Twitter it seems that Twitter doesn’t seem to respect the laws of land of India and countering it that it has its own policies that it follows in India. Twitter’s leadership and team in India actions are only heightening political polarisation, diminishing public trust in institutions, and further undermining the democracy in India which needs to be curbed. In the recent wake of events of Twitter with the Indian Government and its actions not just in India but also around world, it’s time that that we tic tok Twitter out for its agenda on impacting India’s internal peace. Last year when the Chinese invaded India at the Galvan valley, India retaliated with banning of Chinese apps including Tik Tok because of security threat.

How Important is India for Twitter

India is the third largest base for Twitter in the world after USA and Japan. Twitter may lose a approximately 55 million users from India if banned. Therefore, Twitter would have to tow the line of the Indian Government. Currently, Twitter has lost its safe harbour legal status in India and would face more legal cases in India if it continues to operate and be biased towards certain political and religious ideologies in India. Getting banned in India would be a huge set back for Twitter’s international user base. Many countries such as China, North Korea, Turkmenistan, Myanmar, Nigeria and Russia have restricted or totally blocked Twitter in their country.

Oxford Internet Institute has monitored the rapid global proliferation of social media manipulation campaigns, which we define as the use of digital tools to influence online public behaviour in its recent report has found that organised social media manipulation campaigns are now common across the world. It identified in 81 countries in 2020, up from 70 countries in 2019. The map below shows the global distribution of these 81 countries, marked in dark blue.

Global Social Media Manipulation by Country

Between January 2019 and December 2020, Facebook removed 10,893 accounts, 12,588 pages and 603 groups from its platform. In the same period, Twitter removed 294,096 accounts, and continues to remove accounts linked to the far right.

Atma Nirbhar of Twitter – The Koo

Government of India has started endorsing Koo as a microblogging platform as an alternative to Twitter. Aprameya, the co-founder of Koo was also the co-founder of Taxi For Sure (now Ola). He had worked in one of my healthcare venture where he was moonlighting to start up Taxi For Sure. I had been one of the early stage investor in his venture then. He is focused to making Koo a success in India and already entered Nigeria after the ban of Twitter. Recently, Koo has raised USD 10 mil to build and expand the reach of their platform. Last evening, I had a call with their team and provided them with points for enhancing their product from the user point of view. I am sure that Koo would emerge in moving the 55 million users of Twitter in India on their platform as it grows in popularity.

Disclaimers: My Koo handle is IamKK. My main go-to social media platform is Linkedin where I am amongst the first 0.25 mil users and I am still going strong on Linkedin. I have suspended my Twitter handle 3 time in the past and hate the constant ‘We Miss You’ emails from Twitter every week.

A Tale of Two Medical Systems: Revolution Ahead?

Background

The current spat between the Indian Medical Association (IMA) and Baba Ramdev of Patanjali is like a modern version of Charles Dickens’ famous novel A Tale of Two Cities, that led to the French Revolution. The Federation of Resident Doctors’ Association (FORDA) has decided to execute a Black Day on the 1st of June against the controversial statements made by Baba Ramdev against Allopathy and the video shared by him on Twitter. These activities by the allopaths are only goes on to strengthen the value proposition of Alternative Therapies and Indian Traditional Medicine in the minds of the consumer and view IMA and the Allopaths with suspect. The louder the decibel in media the faster would be the Medical Revolution against Allopathy.

Having led the world’s first Integrative Medicine Partnership at the Institute of Ayurveda and Integrative Medicine (IAIM) and served their Advisory Board, I would like to request both sides to set aside their differences and work towards delivering innovative integrative solutions between the two systems for the consumers before it is too late that the consumers bring about a Medical Systems Revolution. Here are some of the points and issues that I would like to lay down for the jury of the consumers to judge and adjudicate.

Investor Perspective: Larger Flow of Investments in Indian Alternative Therapies

Investors and companies invest in opportunities where they see money and value proposition for the consumer’s needs. Let’s understand from the consumers point of view the world over which is becoming more and more skeptic of the allopathic system and their preference towards Indian Traditional Medicine or Alternative Therapies and Medicine for treatment and wellness. Our annual Healthcare and Sciences Heatmap 2021 Investment Heat Map | Kapil Khandelwal (KK) every year is measuring the investment in different sectors including Alternative Therapies. Our conclusion is that Indian Alternative Therapies and Medicine have been gaining wider consumer acceptance and affirmation leading to increased investment activities. Apart from the shift from Allopathy towards Some of the key drivers for investment in this sector are:

Economic growth and rising incomes
Rising per capita expenditures on healthcare products
Low cost of production
Improvements in the distribution network
Increase in accessibility in both urban and rural regions
Awareness programs and subsidies
Rise in non-communicable and chronic diseases

It’s not Baba alone who is the key enemy of the allopaths As per our analysis over 60 corporate groups, pharma and consumer companies, including Multinational Companies (MNCs) have diversified into Indian Alternative Therapies and Medicines with an overall investment of over INR 80000 crores. Moreover, as a boost to this sector, the government recently introduced an economic stimulus package under the Atmanirbhar Bharat and has allotted INR 4,000 crore to the sector for promotion of herbal cultivation. The move aims to cover 10 lakh hectares (24.7 lakh acres) under herbal cultivation over a period of two years

Defamations Cannot Muffle Consumer’s Choice

Nearly 75 per cent of Indian households already use some form of Ayurveda to treat a variety of problems. The writing is on the wall for Allopathy during the current Covid Pandemic, when those who were the forbearers of medical treatment had no answers to treat Covid and the consumers themselves had to search for home made solutions to build immunity and treat mild forms of the infections themselves. Rather than take the prescribed Allopath Doctor’s prescription of artificial vitamins, zinc and tablets, etc. consumers preferred gilroy, kali mirchi, methi, nimbu pani, turmeric, kada, etc. Where was IMA hiding in 2020 with a mass campaign to debunk all these stuff that the consumers were ingesting based on Indian Alternative Therapies and Medicines. I am sure with the current spat between the Baba and IMA allopaths, pharmaceutical companies, doctors and others seem to fear that their dominance is at stake is very apparent.

Indian Alternative Therapies and Medicine are Learning from The Chinese Traditional Medicine

Indian Traditional Medicine and Chinese Traditional Medicine are equally older than Allopathy. However, Chinese export over 5 times more in value their traditional medicines to the world than the Indians. The Chinese were able to lead this sector globally by publishing and sponsoring enough research on quality, effectiveness and safety of their traditional medicine. Moreover they were able to invest aggressively in research in combining their traditional medicine with western medicines into integrative medicine. Why is there no spat between Chinese and the large pharma companies of the West?

India is learning from the Chinese catching up by investing heavily on:

Product innovation is the core to the healthcare solutions that consumers are seeking against allopathic medicine
Study Ayurveda and Alternative Therapies by using the methods and means of western medicine. (As a side note: I know for sure that the same Baba recruited one of my ex-colleagues who was from allopathic drug discovery having worked in US and India to set this up at his Patanjali Research. I am sure he has some aces up his sleeve when he is challenging IMA in the courts rather than just tendering an apology.)
Innovate the basic theory of Indian Alternative Therapies. Different from the western medicine which starts from the molecular biology, Ayurveda is researched and developed based on systematic biology of Kafa, Wada, Pitta. Clinical trials and research is strengthening this potential
Big Data solutions into health informatics to empirically proving where Allopathy stops and Ayurveda starts. At IAIM, there is a large initiative to collect data to prove what limits Allopathy and where Ayurveda benefits the consumer.
Integrating genetics with the systematic biology of Ayurveda leveraging the big data. Apart from the phenotype, genotype and other information is strengthening innovation in the products.

So, my concluding comment on this is spat between Ayurveda and Allopathy is that it’s a lose-lose for both not just in India but internationally giving the Chinese Traditional Medicine a chance to grow its pie internationally. The win-win solution for both the sides is not to prove who is right or wrong on their claims and counter claims and defame both the systems of Medicine in India but to work out an integrative medicine solution between the two. Else we are heading down to the wire on a medical revolution like the Tale of Two Cities dictated by the consumers choice and preferences.

Ask What You Can Do for Me, My MP and MLA

Vaccine Politics and Funding

Background

India is the world’s leading vaccine producer. However, a lot of discussions in the media by the politicians blaming the Center for the shortage of vaccines has been doing the rounds. One politician even went to the length of sharing the ‘formula’ of the vaccine to other so that they can manufacture the vaccines. A lot of the noise on the increased supply has been creating smoke screens and mirrors to deflect the current mismanagement and blame game between the center and the states for the second wave of Covid. India had set up its vaccine strategy which was

Phase 1: Healthcare and other front-line workers, while gradually opening it up to the 45 plus age group.
Phase 2: Vaccination for all persons above the age of 18 years from 1st May 2021 under phase 3 of its vaccination
From 1st May, under a liberalised & accelerated phase, vaccine manufacturers would supply 50% of their monthly released doses to the govt and would be free to supply the remaining 50% doses to the state govts. And in the open market at a pre-declared price. States are empowered to procure additional vaccine doses directly from the manufacturers. So far, many states have placed their orders directly with the manufacturers and most states have decided to provide free doses to adults. That said, vaccination will continue as before in govt vaccination centers, providing free of cost to health care workers, front line workers and all people above 45 years.

In between, Investeq, a leading financial analyst states in its report Vaccine Supply Modelling for India: Supplies set to improve, Foreign Vaccines to make a big difference Vaccinations: Total spend of $8 billion on Covid vaccines for India in 2021: Investec, Health News, ET HealthWorld (indiatimes.com).

Why is this noise and panic been created? First the politicians, then some equity investment analysts and then even some scientific journals like the Lancet have started voicing this issue of shortages of vaccine all-together. Is this a foreign vaccine lobby playing to put pressure on India to buy their vaccine as India is one of the biggest markets that they cannot ignore as demand saturates in the US? The second issue is why should states or their politicians not fund the vaccine costs for their constituencies?

Indian Vaccination Drive versus The World/China

The chart below shows that India has started out early and is better in its vaccination drive than 90 percentile of the countries of the world.

Let’s understand that India is one of the most inhabited countries of the world. Their nearest neighbour China does not even provide information on their immunization status and yet report near zero Covid cases these days. China has procured for only 13% of its population while India 18% of the population so far.

Country	Vaccine	Amount (USD Mn)	Dosage	Population Covered (Mn)
India	AstraZeneca (Covishield)	417	2	209
	Covaxin	80	2	40
	Sputnik V (Russia)	3.15	2	2
Total			500 Mn	250

China	Sinopharm	177	2	89
	Sinovac Biotech	118	2	59
	CanSinoBIO	30	1	30
	Anhui Zhifei Longcom Biopharmaceut	18	3	6
Total			343 Mn	183

Asking our MPs and MLAs to Pay for the Vaccination

India has already administered 185 million doses. The current split is 166 million of Covishield and 19 million of Covaxin. There are around 315 million doses that has already been paid for. This would cover around 25% of our population. We will need another INR 75,000 crores to fund the immunization program to reach the Covid herd immunity. Now comes the political issue that some of the States want to deliver the vaccine free of costs to all in their states and do not want to pay or have the adequate budgets. Therefore the issue of political blame game between the Center and the States. If you see the current vaccination drive across the districts, some have a higher rate than others. When we dissect the same information as per Parliamentary there is a surprising revelation. Some of the Parliamentary Constituencies has performed better and are not correlated to the district coverage of the immunized population.

So why not decentralize this process of vaccination to the grassroots to the elected MPs and MLAs for their electorate so that all the politics of vaccine supply is nipped in the bid. We have 543 MPs and 4215 MLAs in India. An MP gets INR 5 crores while the MLA get INR 2 crores per annum to be spent on their in their constituency for the local development. This comes to INR 2715 crores per year from Lok Sabha MPs and INR 8430 crores per annum by the State MLAs. Over 5 years this amounts to INR 55725 crores. History shows that hardly 25% of this money is spent. As Covid is a black swarm event for the country, the next 5 years of the MP and MLAs Local Area Development Spend is advanced right now so that they can procure the vaccines for their constituency electorate and get them vaccinated as per the vaccination strategy announced. This will also ensure that the blame game between the parties and the Center and State is put to rest and the elected representative are put to work to deliver the results of the vaccination to their electorates.

Health Economics of Tomato!

Tomato Versus Zomato

Background

Finally one of the unicorns in the foodtech space has turned profitable. Zomato is going public with its IPO. With public money it will raise, will also come the public scrutiny of what it does to the public and society at large. Here are some of the data from the Zomato prospectus that summarizes the scale of its business model and its impact on Indian society.

Total reach of Zomato is in 526 cities
It has around 350,000 restaurants listed
Around 41.5 million people visit its app or website in a month of which around 11 million people place orders
It make around 400 million food deliveries in a year (averaging around 3 deliveries a month per user who places orders on Zomato)
Zomato earns around INR 90 per order of food. Their gross order value in 2020 was around INR 230 (increased substantially during lockdown)
Around 160,000 delivery partners are employed in the 526 cities averaging around 300 delivery partners for 3 shifts on 24/7 operations
Industry experts say that the delivery partners drive around 6 kms (during lockdown it was 7.5 kms) from their point to restaurant and the user delivery location to meet the time commitments of 30 minutes. The radius for the restaurant to the user comes to around 5 kms (during lockdown it was 6 kms)

I am assuming the metrics for Swiggy would be around the same metrics as Zomato. Both the Food Delivery Apps must be providing tremendous time and place value to its loyal consumers but at what economics. Let me debunk this now.

Economics of Food Delivery Apps in India

Assuming 800 million food deliveries with an average radius of 5 kms, the total distance traversed would be around 4 billion kms in a year. This is equivalent to travelling between earth and Neptune. That’s a long distance in terms of the food delivery only! The cost incurred for each food delivery was INR 50 per trip. The total cost incurred and cross subsidized by the Food Delivery Apps amounts to INR 4000 crores in 2020. This costs 10 Mars Missions from India in a year!

Now let’s turn to the carbon emission of the 2-wheelers used by the delivery partners. Assuming 4 billion kms travel would require around 80 million litres of petrol for the bikes in a year. They would release around 186.16 million Kgs of carbon in the environment assuming all the bikes are 4-stroke engines. That’s not a great environmental impact! I am not assuming the impact of plastics and other packaging material used by the restaurant partners and dumped into our cities dumps every year as this is not the responsibility of the food delivery apps but the consumer and the restaurant partners as a choice.

On an average INR 230 per order would provide around 1000 calories worth of food assuming all is healthy food ordered. The impact that the consumer feels by getting time and place value is hugely negative. So far these companies doing food delivery were not in public scrutiny but the reality is very negative. Are we creating Tomatos out of the Zomato’s consumers?

Not healthy for the Food Delivery Apps Companies, their investors or their consumers.

Health Economics of Tomato!

Now lets focus on the health of the tomatos who order food. I am assuming that they are busy enough not to be able to cook or step out to the restaurants and are intelligent enough to be aware of their health risks and well being and are only ordering bunk food (anti thesis of junk food) as nobody likes to eat healthy food which is not so delicious to the taste buds. At INR 230 per average order they are consuming around 1000 calories of food. As per ICMR the recommended daily calorie intake is 2100 Kcal for urbanintes. So the average order on food delivery apps is equivalent to a single meal which is around 800 kcal .

Let’s turn to the fitness. WHO recommends that a fit person should walk 10000 steps a day. This is around 8 kms a day. The 80 million consumers of the food delivery apps (Zomato and Swiggy divided equally) would be walking around 230 billion kms in a year. This is 60 times more than what the food delivery partner of these apps travel in a year. So, the question is, what is the health risk of those who order food on these apps really walking their quota of daily distance and prefer instead the meal right on their doorsteps?

Based on the penetration of cities of food delivery and the health risks penetration, the Tomatos are equally penetrated in states where the health risks are fairly high and shows a very strong correlation to food to be served at their doorsteps.

The remedial health issues and what the public subscribing to the IPO of Zomato should be inquiring into is a subject matter of another blog which may come some other time post IPO.

Disclaimers: I do not have Zomato and Swiggy Apps installed on my mobile phone and do not order any food from the food delivery apps. I am not an interested party in pooping the party of Zomato’s IPO.

Covid Apartheid-Complete State-level Nationalisation of Hospitals?

Covid Apartheid

Covid Apartheid-Complete State-level Nationalisation of Hospitals?

Background

There has been news floating on the WhatsApp on complete takeover of private and charitable hospitals by the Maharashtra Government. MAHARASHTRA TAKES CONTROL OF PRIVATE COVID HOSPITALS, FIXES DAILY RATES – The Daily Guardian. The article was published on May 7, 2021 and quotes Sudhakar Shinde, CEO, State Health Guarantee Society saying, “We have issued this order as per the suggestion of both the ministers.” This maybe a fake news as Sudhakar Shinde succumbed to Covid on Oct 10, 2020. IAS officer Sudhakar Shinde passes away in Pune due to Covid-19 | Hindustan Times

However the issue here is for debate is: Should the State Governments Nationalise Hospitals? Second issue here is the alleged hospitals charges being imposed by the private hospitals and how do we deal with it?

Private Hospitals Take Over in 2020 Wave one of Covid by State Government

As per the announcement last year in April 2020, 80% of the beds of the private and charitable hospitals in the state were taken over by the State Government for managing the first wave of Covid. As per the arrangement, the private and charitable hospital owners were free to charge their prices for the remaining as per their operating costs and charge masters. The citizens had the choice of going for treatment to the private sector on their own or request the State Government to allocate a bed in any of the hospitals in the state whether Government or Private as per the rates announced by the State Government.

Covid Apartheid-The Consumer Right of Treatment if They Choose

Last year a famous Indian Celebrity and Film star tested Covid Positive and was admitted himself and his family members to a private hospital in Mumbai. Amitabh Bachchan tests Covid-19 positive, admitted to Nanavati hospital (indiatimes.com). He had not approached the State Government for bearing his treatment costs. There was no negative media outbreak on how exorbitantly the celebrity was charged for his treatment and whether the private hospital in question chose to offer their services on their quota of beds under their management to the said celebrity free of cost, or at subsidized costs or at full price. Had the said celebrity in question chosen to request for his treatment to the State Government, he may have been admitted to Cooper Hospital or any other hospital facility that the State Health Officer (SHO) deems fit to allocate. But the said celebrity choose to deal the situation on his own and contract with the private hospital at a price which is agreed between the two parties and is mutually binding upon between the two parties. Similarly, if citizens opt for private hospitals on their own will, why should there be a hue and cry that there is a differential of prices between the State Government mandate prices for the beds being managed by the State Government in the private hospitals leveraging their infrastructure and staff and the prices being charged to the celebrities and those who can afford to pay the full price and exercise their right to treatment at a certain private hospital exercising their option to pay out of pocket or through their health insurance.

I call this Covid Apartheid. Therefore there should not be fake news escalations about the exorbitant charges. Covid emergency situation is like an SOS as like a heart attack. You have to either treat the person or if let untreated without medical intervention the person dies. So it is catastrophic. If a certain private hospital charges INR 10 lakhs for an open heart surgery and the State-level prices under various healthcare schemes is as low as INR 60,000 (in Karnataka), the real cost of which is much higher as the State Government is cross subsidizing through the tax payer’s money and budgetary support, the media should not make a mole out of nothing. It’s the choice exercised by the individual punting on his health and wealth. There cannot be an apartheid comparing the prices and the quality of services delivered. So is the Covid. The media should stop amplifying negative news about the pricing of services in the private hospitals. They are comparing apples and oranges and want an apartheid on the ability to pay and enjoy different standards and services between different classes and masses.

Dealing with Exorbitant Prices by Private Hospitals

There have been mechanisms in place for any adverse and or exorbitant prices being charged and how to escalate and settle these issues whether it is out of pocket or through a Third-Party Administrator (TPA) of the Healthcare Insurers. Let us understand that no private sector hospital in this country wants to profiteer. I agree with the media that there are rogue private hospitals who may have out of greed charged exorbitant prices playing on the situation. I too was a victim of such a private hospital when I was suffering life and death situation on a Covid like symptoms way back in 2012. However, I settled the issues through various redressal mechanisms in place including the malpractice by one of the treating doctor of the private hospital.

State Nationalisation of Private and Charitable Hospitals

Let us understand it cost over INR 1 crore to set up a hospital bed. If the State Government takes over 80% of that capacity and assuming that the state reimburses INR 10000 per day for those beds it has taken over, it would take around 6-years for the hospital to break even on their capital and operating costs. The hospital operator has bank loans and other liabilities to settle for the risk they have taken to set up the facility to treat their out of pocket and insurance customers. To offset these liabilities and daily losses on the State managed beds in their hospital, the private operator has to offset that from the remaining 20% of the beds it is free to charge whatever prices. The State Government has not taken over the proportionate liability of 80% of beds taken over. If you do the maths, it would require the private operator to charge anywhere from INR 45,000 to INR 90,000 per bed per day just to cover their costs.

We know the healthcare outcome of private sector hospitals and government hospitals. Therefore, there is a price differential. Let me give you an analogy here which is a bit far-fetched. From tomorrow the State Government says that 80% of your private wealth management will be under the Private Sector Bank will be managed like Public Sector Banks (PSU). PSU banks deliver Hindu rate of return of say 3%pa while the Private Banks deliver 15%pa on your money charging 3% fees for the wealth under management. So now you will get 3% pa return on 80% of your wealth banked while 20% of will deliver 15%pa. Will the media start writing that Private Sector Banks are earning exorbitant returns of 15%pa for the rich and the poor laborer who is banking and saving with PSU Banks is just getting 3%pa. Would you allow your personal wealth to be managed like a PSU Bank? Similarly will you allow your health to be put into PSU Hospital hands if you value it? Its your call and there is a price to pay.

We know the outcomes of Bank Nationalisation of the earlier era. Do we need to subject the healthcare sector to state nationalization?

Should We Impose Complete Lockdown Now?

Background

Our Supreme Court has directed the Central and state governments to consider imposing a ban on mass gatherings and super spreader events. “We would seriously urge the Central and State governments to consider imposing a ban on mass gatherings and super spreader events. They may also consider imposing a lockdown to curb the virus in the second wave in the interest of public welfare,” the SC said.

Let us understand that the national lockdown in the first Chinese Wuhan Virus Wave was to create the requisite infrastructure and capacity to ensure that the country does not go into a crisis and the 7-day moving average (7DMA) of infection does not increase the stipulated doubling rate of 1 day. Moreover, the cost of lockdown to the economy for a single day of lockdown is around USD 6.0 billion (INR 45,000 crores approx).

In the second wave, the issues are different. We have our 7DMA of infections is much lower and the doubling rate is much higher. Moreover, as the immunization drive picks up, we will see the two parameters of 7DMA and doubling rate become even more manageable.

So the issue in front of us is, should we impose a complete lockdown and for how long taking cognizance of the Supreme Court directives.

How Far Are We From the Peak in this Second Wave?

In order to arrive at a predictable view of how long should India and its states go into a lockdown and even out the daily economic losses to the country, there are several parameters which we need to consider:

Second Covid Wave in 12 countries before India
Second Covid Wave Peaks in Different States and Cities in India
Covid Immunisation strategy

Second Covid Wave in 12 Countries before India

we can learn from the other countries which have gone through the second wave before India. Based on the learnings from these countries, our Central and State Governments can work out a formula to impose lockdowns and unlockdowns without hurting the economic activity in the country. The table below gives out the duration of the second wave (in days) and % of population that was infected during the Second Wave:

While it is pretty apparent that each country reacted to the second wave differently. The chart below shows how effectively did each of the 12 countries manage the second wave.

Spread of the Second Wave of Chinese Wuhan Virus

Mexico, Turkey, Israel has the second wave duration of less than 100-days, while Germany and Canada had a duration of over 200 days. The peak of the Second Wave was around 120 days (ie 4 months) as an average). The average population that was infected in these 12 countries was around 2.5%.

This is valuable information and analysis for us to predict where India is in the second wave.

Second Covid Wave Peaks in Different States and Cities in India

Maharashtra including Mumbai was the first state to begin with the Second Wave in India. It has already seen the peak and is around the global average of around mid-point of the 120 days wave (ie. 60 days). We will see India as a country peaking by mid-June 2021, unless we solve all the infrastructure and logistical nightmares which some cities like Delhi is undergoing.

WhatsApp Image 2021 05 04 at 08.40.09 — Analysis by IIT Kanpur Prof Manindra Agrawal

The other silverlining is that many other Indian cities are already in their peaks. An interesting analysis by IIT Kanpur Prof Manindra Agrawal shows.

Covid Immunisation Strategy

As I have already written, our Covid immunisation strategy needs to be reworked. It’s not the political compulsions and broad headlines. We need to immunize over 15% of our population by Mid-May 2021 which we have not yet achieved and most likely going to miss the target for the total duration of the second wave and the imposition of nation wide lockdown durations to recede.

Therefore, the opportunity costs for the country in reducing the duration of the lockdown in the second wave is huge provided we implement our covid vaccine immunization strategy and coverage astutely. Invest, invest, invest in immunizations and make it free for all as an incentive. The rest the statistics at the end to the lockdown will reveal.

No Courts in the World Bear the Economic Outcomes of the Country based on their Judgement!

In Search for An End(Demic)

The Coming of End(Demic)?

I have been speaking with cross section of folks over the last few days. Covid Command Center Officials, Health Ministry Officials, Our Doctors, some experts across the world to understand what we are calling the ‘Second-Wave’ of Covid. Many social media posts, new reports are completely confusing the masses now that a few places have now imposed the so called ‘Second-Wave of lockdown to manage the situation. Let me dissect the situation and ally some of the misconceptions and fake news going around. So here are the issues I am hearing

With increased vaccination rate, there is increased covid infection rate
Are the spikes in coronavirus cases due to more coronavirus testing?
There is very high incidence in Maharashtra and Delhi and will spread across the country after the Kumbh Mela
There is shortage of beds, medicines, vaccines to meet the current wave
What should I do?

So is there an End(Demic) in sight to this Covid?

With increased vaccination rate, there is increased covid infection rate

This is totally incorrect. India had administered 111 million doses of vaccine and covered about 7% of the population with one dose. So there is no correlation between vaccination rate and the spike in the Covid Cases in this wave which is due to the following reasons:

A new double mutated strain of SARS CoV2 has been detected in second wave. This is in addition to Brazilian, South African and UK strain. This new mutated virus has the potential to skip the immunity and even vaccine. This is the reason for re-infection cases & cases among vaccinated people.

It is more infectious & affecting younger population of 18 to 45 years group and this group is “super preader”.
By passing RT-PCR – new COVID cases may not be detected by routine RT-PCR test.
R- value is increasing. This is reproductive value which tells one positive person will infect how many others.
Public carelessness & lack of adherence to COVID appropriate behavior (mask, hand sanitization, social distancing & vaccination).
Pandemic Fatigue

Are the spikes in coronavirus cases due to more coronavirus testing?

No. During a surge, the actual number of people getting sick with the coronavirus is increasing. We know this because in addition to people testing Covid positive, the number of symptomatic people, hospitalizations and later, deaths, follows the same pattern. Therefore there is a correlation.

There is very high incidence in Maharashtra and Delhi and will spread across the country after the Kumbh Mela

It is true that Maharashtra has the highest number of Covid positive cases in India at the moment. However other cities and states are quickly catching up with newer cases showing up with a lag effect. The latest map show the spread. (see the map below)

Covid Wave 2 Clusters and Lockdowns and Restrictions Imposed

There is shortage of beds, medicines, vaccines to meet the current wave

Yes there is a lag in the capacity creation and supply with this sudden surge in this wave. Many of the temporary facilities which were lying vacant as the Covid cases went down were utilized for Covid Vaccine Centers. They have now been been used for the treatment and isolation of Covid patients in this wave. On the supply of the injections, many of the manufacturers had now produced these medicines as the demand for them had reduced since October 2020. They are now ramping up production of Remdesivir and this should be available by next week. On the vaccination front, the politics still continues, while a third vaccine from Russia is being given emergency use approval and should also be available by the end of this month.

What Should I do?

Authorities, doctors, clinics and hospitals recognize that more waves are likely to occur. Here’s what you can do now:

Continue to practice COVID-19 precautions, such as physical distancing, hand-washing and mask-wearing.
Stay in touch with local health authorities, who can provide information if COVID-19 cases begin to increase in your city or town.
Make sure your household maintains two weeks’ worth of food, prescription medicines and supplies.
Work with your doctor to ensure that everyone in your household, especially children, is up to date on vaccines, including your Covid Jab

So is there an End(Demic) in sight to this Covid?

So how will these Covid Waves End? Do we see any endemic in sight? Throughout the pandemic, health experts have tended to set the magic number for herd immunity between 50% and 70%. Some of the data coming in shows that

Presumed ‘herd immunity’ is ‘the combined value of infections + vaccinations as % population > 60%

Let me explain the above formula:

Herd immunity is a public health term that refers to the fact that, when enough people in a community have immunity from a disease, the community is protected from outbreaks of that disease. More than 60% of the population needs to be immune to the coronavirus before herd immunity can work. People might be immune from the coronavirus, at least for a while, if they have already had it, but we don’t know this yet. Researchers are currently trying to determine if, and for how long, people are immune from the coronavirus after recovering from Covid. If it turns out that immunity only lasts for a while, people could get Covid again, resulting in even more death and disability. This is the lesson from this wave.

Our country needs to speed up the immunization rate which may take months before we see an end!

Yeh Hai Bombay Meri Jaan, Saab Hain Covid Se Paresaan!

Mumbai Covid Second Wave

Preamble

Earlier in the last decade I was part of the Healthcare Committee of Bombay First which was assisting the Maharashtra Government in the Mumbai Masterplan 2045. One of the key concerns and recommendations made by the Committee was building the healthcare infrastructure for the city, Mumbai lags behind in beds per 1000 population with several key peer Indian cities such as Gurgaon, Delhi, Chennai, Hyderabad and Bangalore. Alongside the shortfalls in hospital beds, there is also a shortage of healthcare professionals, equipment and infrastructure needed at various levels in the healthcare delivery supply chain. The second wave of Covid in the city has once again proved that the healthcare delivery to the Mumbai residents is again in short supply, be it beds, healthcare workers or vaccines. With the crisis looming large, the city is on the brink of a long second lockdown. Without delving into the politics and finger pointing, I want to point out the gaps.

The Gaps in Healthcare Delivery and Covid Response in the City

Hospital Beds Shortage in Skewed Distribution Geographically

In Early 2000s, Mumbai has around as per the Bombay First report, 24,984 beds. As per the recent Mumbai Municipality report, there are 24,039 beds in 2021 in Mumbai. In other words, hospital beds have actually reduced over the last 20 years in Mumbai. It is obvious that many nursing homes have shut down as the doctor/owner have found it lucrative to monetise their nursing homes to commercial real estate. As a result, Mumbai is amongst the worst cities in India with a bed to population ratio of 1.17 beds per 1000 (as against the WHO norm of 3 beds 1000). It was 1.63 beds per 1000 in 2000. Moreover, these beds have been unevenly distributed in Mumbai. South Mumbai has around three-fourths of the total beds in the city which was the case in 2000. This means as the city expands to the suburbs, no additional bed capacity has been augmented in the last 20 years in Mumbai.

**Map highlighting the Geographical Coverage of Prominent Hospitals in Mumbai**

Second Covid Wave in Mumbai and Skew in Spread

As per the recent Mumbai Municipality Report on Covid, the highest increase of positive Covid Cases in the Western and Central Suburbs of the City in the last 7 days. (See the chart below). While the alarming rate of growth of covid positive cases in these wards would take less than 28 days to double the cases. As compared to 35 days as an average for Mumbai city. While the response to Covid is in the Western and Central Suburbs, the concentration of healthcare facilities is predominantly in South Mumbai. While this is leading to a lot to movement of people seeking admissions to hospitals for Covid treatment.

Spread of Covid Positive Cases in Second Wave till 8 April 2021

Action Plan for the Future

The cost of real estate in Mumbai very prohibitive for private healthcare operators to set up greenfield hospitals unless there are regulations to incentivise them. Various recommendations provided by our Committee is not been implemented on the ground. The Covid Pandemic is a wake up call for the City administrators to buckle up and bit the bullet to accelerate healthcare infrastructure in the city by our planners for the future.

The Second Chinese Virus Wave – Trade Off Between Vaccine Strategy and Vaccine Diplomacy

Vaccine Strategy

The Second Chinese Virus Wave – Trade Off Between Vaccine Strategy and Vaccine Diplomacy

There is a second impending Chinese Wuhan Virus Wave in India. Last few days have seen a huge spike in the number of Covid Cases. States like Maharashtra are contributing to over 50% of th cases in the second wave of this pandemic. There are hints of a lockdown while the immunisation drive is now open to second age cohorts of upto 45 years age. Let’s understand, a lockdown is like celebrating an Easter after the economic crusification of the masses when we have proven our vaccines and immunisation drive should be accelerated to cover maximum population which is at risk. Being a student of epidemiology, it begs to reason out the strategy that needs to be followed for immunisation to win over the Chinese Virus in India and sacrifice the wider world’s do good by supplying the vaccines to other countries when our own country is a a peril. In this blog, I discuss on the various options for India.

Where do Indian Covid Vaccines stand in the World Vaccine Race?

India’s CoviShield (rebranded as Vaxzevria on rest of the world) has received the largest purchase orders by the Governments around the world with over one-fourth of the total are going to be supplied by AstraZeneca/Serum Institute. This is on the backdrop of certain adverse event in certain populations of blood clotting. The next in the race are Pfizer/Moderna which has around one-fifth of the commitments. India’s Covaxine from Bharat Biotech is still lagging behind on the 6^th spot.

India’s Vaccine Diplomacy

Although India is the world’s largest vaccine manufacturer, it has won the race against China’s vaccine silk route strategy to dominate the world Covid vaccine supply very early on. From unconfirmed news sources, around 70 million doses have been supplied by India to the world as part of various initiatives to aggressively outwit Chinese Vaccine Silk Route Strategy. India must aggressively meet its commitment for its country and the world to combat the Chinese Wuhan Virus and its various mutants emerging in the world. India’s success in being transparent in the trials of the vaccine and its efficacy is India’s strength in leading the vaccine diplomacy and emerge as a leader. However, India cannot let its own population face the second wave of the pandemic by short supplying the vaccines in India to its 1.35 billion population meet world’s requirements of over 7 billion population. It needs to secure its own borders from the Chinese Wuhan Virus before it can free the world from the invasion of the virus. This means, India need to repriortise its Vaccine Diplomacy strategy. New emerging is that India has slowed down or halted the supply of the vaccines to the world’s after around 65 million doses supplied already.

India’s Vaccination Strategy

India has already used around 65 million doses for covering around 65 million people (around 2% of India’s population) since the launch of the program in January 2021. The phased roll out of the immunization program is on the basis of age cohorts. After the front-line medical workers, the senior citizens were the first to be covered under the program. The second phase is underway covering population above the age of 45 years. The for India is to immunize over 250 million of its citizens by July 2021. Let’s analyse this scenario in the face of the second wave emerging.

Optimum Population Immunisation Coverage

It is believed that over 50% of the population immunized is the much comfortable situation for any country to manage and control the Covid pandemic. While no country has reached this so far, around 20 countries has performed better in their population immunization drive so far. UAE, UK, Chile, and the US have immunized over 20% of their population. The rest of the 16 countries faring better than India also are accelerating their vaccination strategy by ramping up the procurement and supply of vaccines. India has to also do the same.

Revised Vaccination Strategy in the Face of the Second Wave in India

While India may take some time to reach the 250 million population coverage by July 2021, it must rethink the vaccination coverage strategy. Here are a few suggested ones which obviously do not meet the cannons of vaccination in the face of a global pandemic never faced by the world before.

Total Vaccination of Population in States with the highest Covid outbreak:

In this scenario, India accelerates the immunization and opens it to all the age cohorts in the top-5 states which are contributing to over 80% of the current second wave of cases. These states include Mahrashtra, Kerala, Delhi, Karnataka, Andhra Pradesh, Tamil Nadu. This is going to be politically sensitive as other states which have better managed their Covid situation may let the current situation slip to demand total immunization coverage of their states

Total Vaccination of Population in States with the highest Covid outbreak:

Like the earlier strategy, the top 20-cities are contributing to over 50% of the second wave of the Covid cases. This may also be difficult and politically sensitive.

Open up the double bell curve of the Indian age cohorts at Risk:

At a median age of 27 years, its our 50% of the younger population which has to also be opened up for the inoculation strategy as newer mutations attack this population which is our country’s future productive resource.

While the above vaccine strategy would lead to some amount discrimination and political horse trading. Its time to our review and acceleration of the vaccine strategy. The vaccine strategy adopted by other countries as a benchmark would be another blog for another time. The priority of the immunisation strategy is to avoid another impending lockdown to control the spread of the Chinese Wuhan Virus infections!