Why India is struggling to contain coronavirus: World's second most populous country sees cases surpass China
More than 50 days after Prime Minister Narendra Modi locked down the country, India's human and economic toll is worsening even as new cases of coronavirus continue to crop up in various parts of the country. Where does India stand today?
Lockdown 4.0
India is unique in having implemented a total lockdown for such a long duration in the wake of the coronavirus pandemic. The lockdown has been extended for the third time since it was first announced on March 24 and imposed on March 25. The movements of individuals will continue to be strictly prohibited between 7 pm to 7 am, except for essential activities. Domestic flights, schools/colleges, hotels, and restaurants remain shut. Cinema halls, shopping malls, gymnasiums, swimming pools, entertainment parks, theatres, bars, auditoriums and assembly halls also remain shut.
Coronavirus cases in India
The world's second-most populous nation, according to data compiled by John Hopkins University, now ranks 11th in the global outbreak list. After over 50 days into the world's largest lockdown on May 18, the total number of coronavirus cases in India at 96,169 has surpassed China's tally of 82,954 confirmed cases (numbers till May 17). According to official figures, India has 56,316 active cases, 36,823 have been cured/discharged and 1 migrated.
Between May 17 and May 18, active cases have gone up by 2,370 (there were 53,946 active cases on May 17). Between May 16 and May 17, 911 fresh cases were added. Five states account for the largest share of the confirmed cases as of May 18: Maharashtra (33,053), Gujarat (11,379), Tamil Nadu (11,224), Delhi (10,054) and Rajasthan (5,202). So far, 3,029 people have died in India, including 157 new deaths (2,872 died on May 17). There were 120 new deaths between May 16 and May 17.
What did the lockdown achieve?
It is unclear what the government hoped to accomplish during the lockdown. As India slowly opens up, the question one may have is what would have been different if India had not locked down at all.
"(Between) March 25 to April 14 was the first lockdown and it was (done) without any warning. That was very strange. In 20 days, the reported number of infections grew 20 times, approximately. The economy went down precipitously," Dr T Jacob John, a leading virologist, and infectious diseases expert, told MEA WorldWide (MEAWW). He explained that a two-pronged strategy of social mobilization and universal masks — refusing any service anywhere without masks — would have allowed social and economic recovery while slowing the epidemic effectively. This, he said, would have been "much better than the highly leaky lockdowns."
"These require homework and hard work by officials," said Dr John, a fellow of the Indian National Science Academy. "Extending it beyond the 3 weeks was indicative of lack of a strategy to manage the epidemic. Almost like 'self-justification' that lockdown was the only way the government knew how to confront the epidemic. In my opinion that was unimaginative, and counterproductive. In other words unjustified, as the alternative intervention was very much available," he told MEAWW.
The government's stated objective of the lockdown was to flatten the curve. Last month, the government claimed that India would have been hit with 820,000 cases had it not imposed a nationwide lockdown, citing an internal assessment. The confirmed case numbers are still trending in the upward direction, which may show that lockdown may not have had its intended effect to the extent envisioned.
An unpublished Indian Council of Medical Research (ICMR) study also stated that the virus would continue to spread for over a year, according to a news report published in Article14 on April 23. The report said that "the shutdown would have a limited impact on the spread of the coronavirus, preventing only 20-25% of infections that might eventually be detected at the peak of the pandemic." The lockdown would delay peak infection, the ICMR assessment said, adding that in the absence of a lockdown, daily infections would peak between 100-150 days from the first reported infection; with a lockdown, the peak would come within 150-200 days.
This suggests that the effect of the lockdown has been more to delay rather than effectively control the incidence of peak infections. The stringent lockdown is yet to flatten the curve. Professor Shamika Ravi, a senior fellow at Brookings Institute, who has been regularly explaining the Indian crisis on Twitter, said on May 18, that active cases are still growing in the US, UK, Russia, Brazil and India, and these countries are yet to flatten the curve.
"The overall cost-benefit in India is not favorable. After having increased deaths on other counts, and increased deaths and suffering due to economic distress, you haven’t curbed the coronavirus at all," T Sundararaman, a New Delhi-based global coordinator of the People’s Health Movement, a public health group, told Bloomberg.
According to Dr Rahul Bhargava, director and head, Fortis Memorial Research Institute, Gurugram, without lockdown, the disease burden would have been far more immense in india. "Without lockdown, it would have easily been 7,00,000+ cases. Then our healthcare infrastructure would have collapsed. With the pre-emptive lockdown we have not only delayed the initial surge or peak of the virus but have given ourselves time to equip our healthcare facilities with personal protective equipment (PPE) kits, ventilators, masks and Covid-19 dedicated facilities," he told MEAWW.
Some also question whether lockdown is an effective social distancing strategy for a densely-populated country like India. In Dharavi, Asia’s largest slum, for example, one may not be able to achieve this concept.
Missed opportunities
According to health experts, a lockdown is meant to slow the rate of growth of the virus and buy authorities more time to prepare health systems so that they can tackle the outbreak when it happens. The easing of restrictions appears to be coming primarily because India simply cannot afford to be shut for much longer.
Experts say lockdown is not sustainable beyond a point in a poor country like India, and it imposes enormous costs on the most vulnerable sections of the population. With millions of migrant workers stranded far from home without access to adequate food supplies and millions more pushed into poverty, some have questioned whether the lockdown was worth it. That so many saw it appropriate to walk for days just reach their homes is a testament to the governments’ failure and neglect.
The Modi government recently announced a Rs 20-lakh-crore package in response to the Covid-19 pandemic. "The package may fall short of mitigating the near-term challenges for some businesses, but it is better designed to improve India's medium-term growth potential," said Sonal Varma, chief India economist at Nomura Global Market Research, according to a report.
The bigger problem is that a focus on the lockdown takes away from the crucial question of ramping up testing. Many have questioned whether the government has made the best use of these weeks to plan for an uncertain future. Critical questions have gone unanswered: Is India testing enough people? Does it have enough ICU beds and ventilators to deal with peak capacity? Is there a sufficient inventory of protective equipment for healthcare workers and the general public? Reports of overcrowding at Covid-19 hospitals and the lack of consistent supply of PPE kits indicate not. "Absent any other control measure, lifting the lockdown would allow a resurgence of transmission," the ICMR's draft internal presentation said.
When it comes to hospital capacity, an analysis suggests that India has about 19 lakh hospital beds, 95,000 ICU beds and 48,000 ventilators. “Existing bed capacity is mostly saturated at government hospitals,” says the study by Center For Disease Dynamics, Economics & Policy.
Another report says that states like Uttar Pradesh, Bihar, and Assam have the largest numbers of districts with massive shortages of isolation beds, ventilators, and ICU beds. The information was presented by the central government to states, based on data up to April 23. It said that 183 districts across India have fewer than 100 isolation beds, and 67 of these districts have seen cases of coronavirus infection. Further, 143 districts in India have no ICU beds, and 47 of these have seen coronavirus cases. Another 123 districts nationwide have zero ventilator beds and 39 have seen cases. The government also struggles to tackle corruption, as a report by Moneylife points to massive profiteering on essential masks and PPE kits. There seems to be a lack of political will to openly acknowledge and address such concerns.
The World Health Organization (WHO) has asked all countries to test, trace and isolate, but it is not known what the Indian government's strategies are to make this possible. According to one estimate, India is doing about 0.06 tests per thousand people daily. In the absence of widespread testing, it is impossible to quantify the magnitude of “community transmission,” that is, estimate how many are infected outside hospitals and health care facilities. The government has tried contract tracing via the Arogya Setu app. The adoption of this would be limited to those with smartphones, and even then concerns remain on privacy issues going forward.
"The success rate of contact tracing is equal to 4%. We could obtain a much higher success rate if we had ramped up clinical testing, maybe 10-30%. So it is not how much testing but who gets tested," said Dr John. "We are not blindly testing people. We are doing contact-based tracing and targeted testing and it is yielding results. Our mortality rate is 3.3%, which is far better than many other countries," said Dr Bhargava.
Meanwhile, as India enters into an uncertain future, one expert said that the Covid-19 curve in India may peak in June or July. Dr Randeep Guleria, director of All India Institute of Medical Sciences (AIIMS), told Livemint that since the Covid-19 curve is not coming downwards, India needs an aggressive strategy for containment. "Currently, the cases are continuing to grow at a flat rate, even more at times, so it's very difficult to predict when the peak will come. But a peak is expected near June or July. That is the reason why we need to be prepared for it and more vigilant to bring the number of cases down," he said.