Since the first COVID-19 case was identified in India a year ago, the evidence for COVID-19 treatments has shifted dramatically. Observational research and limited trials from around the world suggested that hydroxychloroquine, convalescent plasma, and tocilizumab may play a role in the early days of the pandemic. The Indian drug regulator was also fast – too quick, as it turned out – to approve two drugs tested in Indian trials, favipiravir, and tocilizumab, despite the fact that the trials didn’t really demonstrate their efficacy. However, when the pandemic progressed and few medical options became available, physicians started to prescribe these experimental therapies widely. In the event of a pandemic, critics have expressed a number of concerns about the widespread use of unproven medications outside of clinical trials without a secure channel for proper and safe COVID-19 treatment guidelines. Would researchers and scientists have treated experimental drugs with more caution in the midst of a pandemic?

In the last two decades, India’s response to pandemics has been consistent and largely in line with WHO recommendations. India concentrated on thorough screening of incoming passengers and quarantine, as well as targeted testing, case isolation, hospital bed extension, and touch tracing. The appearance and rapid spread of SARS–CoV-2, on the other hand, poses unprecedented challenges. Although there are well-established international guidelines for the management of COVID-19, critical care delivery in India faces unique challenges due to the country’s diversity in cultures, processes, healthcare access, and economic inequalities. Some of the challenges of developing and providing critical care services in India for COVID-19 during a pandemic are:

• Dense populations of both rural and urban limit the ability to follow preventive measures strategies like social distancing. 
• The prevalence of patients with type 2 diabetes and hypertension in India is one of the highest in the world which places the population at a higher risk of developing severe COVID-19 disease.
• Unavailability of minimum care for mild COVID-19 patients in rural and urban areas leads to severe infection spreading and the creation of hotspots.
• Limited availability of trained critical care doctors and nurses, non-ICU healthcare staff has led to a strain in the clinical management of COVID-19.
• Lack of hospital beds, oxygen masks, ventilators, PPE, pressure rooms, intravenous fluids. 

The Surviving Sepsis Campaign recommendations for the treatment of critically ill adults with COVID-19 were jointly released in March 2020 by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine (SCCM). While these guidelines apply to both high and low-middle-income countries, there are many barriers to enforcing these recommendations in low-middle-income countries. Three of the best practice statements in these guidelines pertain to infection control: conducting aerosol-generating procedures on ICU patients with COVID-19 in a negative pressure room, wearing fitted respirator masks (N95 respirators, FFP2 or equivalent), and having the most qualified airway operator perform tracheal intubations.