Background

The global increase in COVID-19 cases in 2021 has primarily been due to an uncontrolled surge in South Asia. It is estimated that by 1 September 2021, approximately 1.4 million in South Asians will die due to COVID-19 alone.1 The total number of excess deaths will be much higher—including non-COVID causes, as health systems are on the brink of collapse.2 With 33.4% of South Asians being extremely poor3 and the large-scale loss of livelihood being reported, the region faces a potentially catastrophic future for the ongoing decade.4 However, countries in South Asia continue to remain divisive. This differs from other geographic ‘blocs’ that frequently cooperate on mutual interest issues.5 Tensions in South Asia are shaped by complex domestic, bilateral, intra-regional and international geopolitical factors, despite the region’s obvious geographic, economic and cultural interdependence. A key lesson from the current pandemic is that countries need to share lessons and actively coordinate, complement and supplement each other’s public health responses, especially between neighbours. We present a pragmatic ‘Stronger Together’ agenda (table 1) on critical areas of concern for political, social, medical and public health leaders in South Asia to consider and build on.

Cross-national surveillance for the SARS-CoV-2 variants

The uncontrolled spread of COVID-19 in many parts of South Asia implies that newer variants will continue to emerge. Some variants will inherently display increased transmissibility, infectivity and vaccine/antigenic escape capability, making it difficult for us to track and intelligently act on them.6 Rapidly scaling up capacity for genomics and rolling out countrywide surveillance systems require increased time and resources. Regional collaborative efforts within existing facilities and building a regional network similar to the Indian SARS-CoV-2 Genome Sequencing Consortia are feasible.7 The network can also build capacity within each country in the long run making countries self-sufficient to collect data and strengthen regional surveillance. Linking genomic data with clinical and public health data as well as enabling environmental surveillance will provide a more comprehensive picture of circulating SARS-CoV-2 variants. This is an investment, not only for the ongoing pandemic but also for other endemic pathogens and emerging infectious diseases.

Interconnected and resilient health systems

Health system capacity and human resources for health remain a major regional challenge.8 Healthcare worker density in the region is well below the suggested threshold of 44.5 healthcare workers per 10 000 population to achieve universal health coverage.9 National averages hide the disparities that exist across various geographic, demographic and socioeconomic population groups. The possibility of interconnected and collaborative health systems holds enormous potential, specifically for border areas. Setting up mechanisms for cross-border patient management (relaxed barriers or visa requirements on sharing medical documentation) and regional medical missions is essential from a humanitarian standpoint. Facilitating cross-border teleconsultation by designing more flexible mutually agreed upon regulations will also further boost capacity. At the minimum, peer support groups and tele-mentoring should be put into place. For this, mutual recognition of medical licenses and healthcare qualifications is essential. While close collaborations will be needed for the pandemic response, forming functional mechanisms of public health networking between countries under a long-term regional strategy will be required for developing a shared resilience and preparedness plan.10

Addressing COVID-19 supplies shortage

There is a dependency on aid from the diaspora and from bilateral, multinational and humanitarian aid agencies to secure COVID-19 supplies during the current surge. This is neither sustainable, nor secure, nor without consequences.11 South Asian countries need to jointly invest in the augmentation of dedicated production capacities of essential medicines and other supplies. Much has been said about India’s tremendous capacity as the ‘pharmacy of the world’, not recognising manufacturing capacity in Bangladesh, Sri Lanka, Pakistan, Nepal and other countries in the region. Nationalistic policies and hoarding of active pharmaceutical ingredients by high-income countries (HICs) impede access and scale-up.12 However, such power imbalances can be mitigated to an extent if South Asia acts as a ‘bloc’. Production augmentation alone would not be sufficient—there is a need to agree on shared technology ownership/transfer and an equity-based regional distribution model based on priority groups defined based on assessment of risks and vulnerability.

COVID-19 vaccines specifically remain a crucial challenge for South Asia. In the short term, South Asian countries must act as a bloc to request excess vaccines from HICs, using a collective needs assessment and a diplomatic approach. In the long term, there is a need to re-invent global health mechanisms such as COVID-19 Vaccines Global Access (COVAX). Equity—the defining purpose of COVAX—has been subverted by HICs who had brought vaccines directly from manufacturers and built stockpiles.13 The South Asian bloc, together with others, needs to shift COVAX from a neo-colonial purchase-donate model to a model with regional manufacturing hubs.14 Access to vaccines or essential medicines, a vital component of the right to health, should not be dependent on charitable inclinations, economic or political interests of HICs, or private corporations—a regional effort is required to change the status quo.

Cooperation between scientific, professional organisations and associations

Clinical providers (e.g., doctors, nurses), scientists and public health professionals in South Asia must recognise that there is much context-specific knowledge to be learnt from one another and that collaboration is valuable. Shared challenges include low value, irrational clinical care, unregulated home-grown medical solutions and medical misinformation. Many South Asian countries do not develop their own clinical practice guidelines or the ones that are developed are not of high-quality.15 16 There is an urgent need for medical associations to collaboratively develop contextually relevant clinical practice guidelines at par with global standards. Advocacy for more significant investments in health and health workers is needed. The social conscience needs to realise that pathogens do not understand nationalism, populism or respect borders. There is also an urgent need to fight against irrationality and anti-science in the region jointly. Drawing on the diverse experiences of countries regarding public health responses, vaccine roll-out, diagnosis and treatment capacity would be highly advantageous in designing effective pandemic responses both immediately and for the long term.

The way forward

Focusing on a ‘Stronger Together’ future is a necessary step for tackling health security challenges beyond COVID-19, such as the climate crisis. The longer COVID-19 stays uncontrolled, even in a single country in South Asia, all other countries will be in immediate danger from novel variants and other social, economic and political consequences. Beyond the immediate benefits of addressing the pandemic, a collective regional approach, with global knowledge-exchange collaborations, will be vital for re-imagining the global health structure with equity at its centre.