India did not stockpile COVID protective equipment for health workers despite clear WHO guidelines

The India government took till three weeks after the World Health Organisation issued guidelines about a disruption in the supply of personal protective equipment for healthcare workers before it completely prohibited its export. Rafiq Maqbool/AP Photo
22 March, 2020

On 22 March, as 1.3 billion Indians imposed a curfew on themselves, at the request of Prime Minister Narendra Modi, health workers continued to struggle with the slow-rising horror that India had failed to create stockpiles of personal protective equipment, or PPE, such as masks, gowns, and gloves in the past two months. Modi had called upon the nation to impose the “janata curfew” on 18 March, urging them to make noise from their balconies to support India’s health workers. But it was only the next day that the Indian government issued a notification prohibiting the export of domestically manufactured PPE, three weeks after the World Health Organisation issued guidelines informing countries to expect a disruption in the supply of PPE.

As early as 27 February, the WHO had issued the guidelines, noting, “The current global stockpile of PPE is insufficient, particularly for medical masks and respirators; the supply of gowns and goggles is soon expected to be insufficient also. Surging global demand − driven not only by the number of COVID-19 cases but also by misinformation, panic buying and stockpiling − will result in further shortages of PPE globally.” As described in the WHO guidelines, PPE includes gloves, medical masks, gowns or coveralls, and respirators, such as  the N95 masks. Yet, the Indian government waited till 19 March to issue a notification prohibiting the export of domestically manufactured PPEs and the raw material for the same.

Perhaps the most disturbing aspects of the government’s decision-making process has been the bizarre progression of developments with respect to PPE, as they watched the pandemic approach. On 31 January, one day after India reported its first COVID-19 case, the government’s directorate general of foreign trade issued a notification prohibiting the export of all PPE. But in just over a week, on 8 February, the government amended that order, permitting the export of surgical masks and all gloves. On 25 February, by which point Italy had reported 11 deaths to the virus and over two hundred cases, the government further relaxed the restrictions, allowing eight new items for export. It is inexplicably clear that the Indian government did not make the necessary attempts to forecast the demand for PPE kits, as had been recommended by the WHO. As a result, India’s doctors and nurses have paid the price and will continue to do so, as they walk into this public-health nightmare without adequate gear to keep them safe.

Decisions taken by health ministry, the textile ministry and a government-owned company called HLL Lifecare Limited in the past two months have alarmed health activists and health care workers alike. Several manufacturers have told me that the Indian government has granted HLL a monopoly over procurement of PPE, which has since been selling the equipment at inflated prices. The decision made little sense amid the growing public-health crisis, given that HLL is currently not manufacturing PPEs. As a result, by awarding the company with a monopoly during this crisis, HLL has effectively been given free reign to assemble PPE kits from other suppliers, which it has then been selling at Rs 1,000 per kit. Meanwhile, manufacturers of the same PPE kits told me that they could supply the same at costs between Rs 400–500 if permitted by the government. Moreover, the assembly of kits causes further delays. 

The price gouging has alarmed health activists. Malini Aisola, the co-convener of a non-profit industry watchdog called the All India Drug Action Network, told me that the AIDAN would be writing to the prime minister on 23 March demanding that the HLL be immediately removed as the nodal agency for the centralised procurement of PPE.

“Most grievously, the government’s lack of forecasting has meant that quantities being ordered now will be wholly inadequate,” Aisola said. “The government also did not tap into the manufacturing capacity of the local industry. For example, there is a deep discordance between the orders for coveralls by HLL, which has been pitched at roughly 7.5 lakh till May 2020, and real requirements which could be upwards of five lakh per day.”

Thus, while Aisola estimated that India’s health workers could need upwards of five lakh body coveralls per day, the health ministry estimated—based on questionable forecasting—that it would need 7.25 lakh coveralls up to May. The ministry’s observations are recorded in the minutes of a meeting that took place on 18 March, a day before the government notification prohibiting the export of PPE and its raw material, between the health ministry, the textile ministry and HLL.

The minutes make for a grim read. The health ministry stated that HLL would be providing 7.25 lakh coveralls, 60 lakh N95 masks and 1 crore three-ply masks. But the ministry also noted that “there is a shortage of material and the rate of supply is not meeting the rising demand.” The textile ministry, which is under the minister Smriti Irani, is in-charge of coordinating the manufacture of protective overalls. The ministry has not responded to requests from garment manufacturers to provide more centres that can test and validate the quality of material supplied. But during the meeting, the ministry noted, “Demand is also raised by various State Governments, who have reported the difficulty in availability in the market and the unreasonable price quoted by the few available suppliers.”

The textile ministry further stated, “There is a shortage of Body Coveralls and N-95 masks. The supply should get prioritised as per the criticality of situation, as arising in different parts of the country. Hence, supply of coveralls and N-95 masks should be controlled through Ministry of Health and Family Welfare and procurement should be centralised through HLL Lifecare Ltd.” There appears to be an incongruity between the textile ministry’s recognition of the shortage of PPE and its insistence on centralised procurement through HLL. Officials in the health ministry, who requested to remain anonymous, said that it could take weeks before the ministry receives the orders being placed at present. So far, the officials said, the ministry has not received a single order as no order had yet been placed in advance. Meanwhile, Irani, the textile minister, spent part of the morning on 22 March on Twitter, encouraging a singalong with the banging of pots and pans, to combat the pandemic.

The shortage of material discussed in the 18 March meeting has been a result of ill thought-out, knee-jerk decision to issue notifications banning the export of specific PPE, but not preventing the export of raw material used to make the PPE. “While other countries took measures to not only ban export of PPE products but also raw materials, it did not occur to India to do that till 19 March,” Sanjiiiv Kumar, the chairman of the Preventive Wear Manufacturers Association of India, said. “In the meantime, Indian companies continued catering to foreign governments, which were stockpiling. We also repeatedly raised the need for creating stockpiles of protective gear which were ignored. Despite us reaching out to the ministry and requesting for anti-profiteering measures to be imposed, as early as 7 February, Indian government did not do that. The price of components used to make the 3-ply face masks have gone from Rs 250 per kg to Rs 3000 per kg. Elastics are not available at any price. We are now facing a crisis which is of our own making.”

Meanwhile, doctors across the country feel abandoned by the government. A resident doctor at a government hospital in Maharashtra spoke to us on the condition of anonymity. “I don’t need claps,” the doctor said, referring to the prime minister urging everyone to clap for India’s healthcare workers. “I need safety gear. ” She added, “This is like sending fire responders without any equipment right into a raging fire. I have sent my family away for three months. The goodbye felt final. I am not sure if I will see them again. To know that I have to care for COVID patients without any safety equipment is unsettling.”

From 20 to 22 March, the number of confirmed COVID-19 cases reported by the Indian Council of Medical Research increased from 206 to 341. But instead of addressing the urgent needs of the healthcare workers, at 5 pm on 22 March, Indians came out to their balconies to imitate Italian lockdown singing to thank healthcare workers for their service. The move has no scientific merit, and will not boost the morale of healthcare workers who are anxious about the coming tsunami of cases.

Correction: An earlier version of this article incorrectly stated that Malini Aisola of the All India Drug Action Network said that the AIDAN and the Preventive Wear Manufacturers Association of India would be writing to the prime minister on 23 March demanding that HLL Lifecare Limited should not be given a monopoly on the distribution of PPE. Aisola said that only the AIDAN would be writing the letter. The Caravan regrets the error.