Coronavirus: India, the world’s second-most populous nation, is totally unprepared for outbreak, says expert
India, so far relatively immune from COVID-19, now finds itself in the middle of a scare with at least 29 confirmed cases. According to experts, the world’s second most populated country does not have a strong health infrastructure to tackle a new disease outbreak, particularly if the numbers escalate and there is widespread community spread.
According to Dr T Jacob John, a leading virologist and infectious diseases expert, the current infrastructure is not robust enough and it is not even geared to handle a flu pandemic. “So how can we expect that it will be able to tackle COVID-19?” questioned Dr John, a fellow of the Indian National Science Academy.
“The global mortality rate for the H1N1 flu is around 0.1%, which is one in a thousand people. In India, the H1N1 mortality rate is around 5%, which is 50 in a thousand people. These numbers are an indication of our poor health system,” Dr John tells MEA WorldWide (MEAWW). He retired from Christian Medical College, Vellore, as Professor and Head of the Departments of Clinical Virology and Microbiology.
Dr John fears that the new coronavirus might end up becoming one more disease that India will add to its list of infectious and communicable diseases.
“If we don't diagnose on time, disease transmission will be massive. India is already burdened with many diseases such as TB, pneumonia, malaria, E.coli, diarrheal diseases, among others, and COVID-19 will end up becoming one more. We will just take it lying down, passively accept it and say nothing,” he says.
He said his “intelligent guess” is that India is unlikely to take COVID-19 very seriously once the epidemic settles down as an endemic.
“Look at influenza. Is the infrastructure robust enough to control influenza? You think it is being diagnosed at all primary health centers, mohalla hospitals, district hospitals. The answers are no. If COVID-19 becomes endemic everywhere, it will become another influenza-like illness,” he added.
What are the current numbers in India?
The situation is currently evolving. As of March 4, a total of 28 confirmed cases of COVID-19 have been reported. This includes 17 cases in Jaipur 17, one in Delhi, six in Agra, one in Telangana and three in Kerala. Laboratory confirmation is pending for two cases in Telangana. Hospital isolation of the cases, tracing and home quarantine of the contacts are ongoing in these localities.
India's Health Minister Dr Harsh Vardhan said 27,000 people have been placed under community surveillance.
What measures have the government taken so far?
Dr Vardhan chaired a meeting on March 4, asking states and union territories to identify possible quarantine facilities, “strengthen core capacities” for disease preparedness and surveillance, and focus on “cluster containment strategy to avoid widespread community transmission.”
“Cluster management guidelines were shared with states and they were requested to operationalize the guidelines,” says Dr Henk Bekedam WHO Country Representative to India, in a statement.
Decisions were taken to rapidly implement the opening of proper testing, isolation and quarantine facilities in various parts of the country, down to the district level. So far, 15 labs were functional to test the novel coronavirus and more are being made operational. Two changes were announced on March 4: universal screening at all international airports and sea-ports and mandatory filing of declaration forms of places visited by those returning from abroad.
All international passengers entering India will now be screened for coronavirus at airports. Earlier, it was restricted to 12 countries. According to the travel advisory, Indian citizens have been advised to refrain from travel to China. People traveling to China will henceforth be quarantined on return. For those planning a visit to India from China, existing visas (including eVisa already issued) are no longer valid for any foreign national traveling from China.
Indians have been advised to avoid non-essential travel to Singapore, Republic of Korea, Iran, and Italy. People coming from the last three countries or those having a history of travel to these countries may be quarantined for 14 days on arrival to India.
The Health Ministry has created a coronavirus helpline number and an email id. It is coordinating the activation of a GIS mapping of ‘disease hotspots’ and the availability of medical facilities.
Government measures not enough in a fragile health system
Between 2001 and 2011 census, India grew by 181 million people. Health infrastructure has not been able to keep pace: most hospitals in India are overburdened, understaffed and ill-equipped.
India has a shortage of an estimated 600,000 doctors and 2 million nurses, according to a 2019 report by the US-based Center for Disease Dynamics, Economics & Policy (CDDEP). It says there is one government doctor for every 10,189 people. This is far less than the WHO-recommended limit of 1: 1000.
“Apart from its sheer size, India is cause for particular worry because of the density of its population: 420 people live on each square kilometer (about 0.4 of a square mile), compared with 148 per square kilometer in China,” reports Bloomberg.
The numbers are alarming as the density of India’s population puts tremendous pressure on an overcrowded healthcare system. COVID-19 spreads fast. And thanks to India’s sheer size, high migration rate, and bad hygiene standards, experts say if community transmission happens and the contact tracing process gets complicated, it will be a huge test for a fragile health system.
“The real test (for India) would be whether we can respond to the sort of situation that Wuhan faced, with hospitals and clinics simply being overwhelmed by the number of patients. H1N1 is now a regular feature of the influenza season, so its impact is much the same as any other influenza which leads to a small percentage of fatalities, especially among the old,” Gautam Menon, professor of physics and biology at Ashoka University, Haryana, tells IndiaSpend.
In light of the public health experts’ recommendations to avoid big public gatherings, India decided that all government departments and ministries will consult the Ministry of Health before organizing conferences and international meetings in the country at present.
India’s Prime Minister Narendra Modi tweeted, “Experts across the world have advised to reduce mass gatherings to avoid the spread of COVID-19 Novel Coronavirus. Hence, this year I have decided not to participate in any Holi Milan program.”
According to Dr John, a robust healthcare system has two aspects - universal healthcare and public healthcare, both of which must be strong. “And India does not have either. Is our primary healthcare system good? If a farmer falls sick today, does he have a rightful place where he can go and have access to medical care? The answer to these questions is no,” he tells MEAWW.
He adds, “Universal healthcare is essential so that everyone can get some medical attention. Access and referral channels should function in full force. This happens in countries such as the UK, Germany or Norway. But that’s not the case in India.”
The country’s health spending is also among the lowest in the world: 3.7% of gross domestic product. “That’s left India with a patchwork of overcrowded public hospitals, and private ones that are unaffordable for many people,” reports Bloomberg.
Fighting misinformation
India has another enemy: misinformation. In January, the Indian government issued an advisory with no proven scientific basis, advocating homeopathy for "prevention" of the virus and Unani medicines for “symptomatic management” of the infection. There is no cure or vaccine currently for COVID-19.
The Telangana state government’s AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy) department recently started distributing what it claims to be prophylactic homeopathic medication.
Subsequently, it issued a clarification stating that the advisory issued is only indicating “general precautionary measures to be followed in the context of such viral diseases (like COVID-19).”
So how can India prevent further transmission?
“People are quarantined to prevent further transmission. Those containment measures must continue. However, we must realize that the infection might slip right through our fingers and that’s where the natural course of events will happen,” says Dr John. He said a time will come when airport screening will not be efficient or sufficient enough.
“What we are doing is right for the time being. But as the scene changes, it may not be sufficient to stop the spread,” he adds.
Dr T Sundararaman of People’s Health Movement (PHM) tells NewsClick, “We are doing better in terms of restriction in the point of entry. However, it will be successful only to an extent. It is partly good luck so far. Many people who are coming from outside will not be picked up by the thermal scanners at the airports. This is because they don’t necessarily have a fever.”
Lessons from Kerala
Kerala in southern India had reported the first three cases -- medical students who were undergoing training in Wuhan and evacuated and brought back. The state’s response was swift, and the three have now recovered.
The state's health department officials traced those who returned to Kerala from infected areas and isolated them even if they had minor symptoms. The rest were home quarantined.
“Kerala’s success has been thanks to the fact that these students returned from Wuhan and were quickly tested and quarantined during the infectious period. The same goes for the contacts. There was no secondary infection,” Dr John tells MEAWW.
Kerala has been publishing daily updates about quarantine, contact tracing, tests, and hospitalizations. The state also issues daily bulletins.
“Single window communication channel established with all district control rooms for high priority communications. For providing psychosocial support to the families of suspected persons, 215 persons have been deployed across the state,” says a bulletin.