Failure of lockdown-centric strategy

Blame game

Print edition : May 22, 2020

Union Health Minister Dr Harsh Vardhan and Minister of State (Health) Ashwini Choubey during a videoconference with Health Ministers and officials of Gujarat and Maharashtra, in New Delhi on May 6. Photo: PTI

Fig. 1: A timeline of confirmed COVID-19 cases up to May 7 with y-axis as a log-scale. Photo: Graphics courtesy: ISI, Bengaluru

Fig .2: Cases during May 1-8. The growth factor in the period shows the growth curve is yet to cross the inflection point. Photo: Graphics courtesy: ISI, Bengaluru

FIG. 3: A comparison of growth rate of case in States against the reference line for exponential growth on a log-log plot with log scale on both axes. Photo: Graphics courtesy: ISI, Bengaluru

FIG. 4B: Growth rate comparison of Maharashtra, Gujarat, Delhi, Punjab, Tamil Nadu and West Bengal. States like Kerala and Telangana have fallen off the reference straight line of exponential growth compared to the problem States which are still on the exponential phase. Photo: Graphic courtesy: ISI, Bengaluru

Fig. 4a: Case timeline comparison of Maharashtra, Gujarat, Delhi, Punjab, Tamil Nadu and West Bengal. Cases in Kerala and Telangana have levelled off compared to sharp increases in the six problem States. Photo: Graphic courtesy: ISI, Bengaluru

Faced with the failure of its lockdown-centric strategy, the Centre blames the States and the people for the rising graph of COVID-19 infection in the country. Grossly inadequate Union health budgets and the long-term failure to build a robust public health infrastructure have compounded the crisis.

THE growth of COVID-19 infections in India (number of confirmed cases as per government data, to be precise) is yet to “fall off” the exponential growth phase. This can be seen graphically if the timeline of number of cases is plotted with the number of cases on a logarithmic scale graph (where, unlike on a linear scale graph, unit intervals typically differ by a factor of 10). The graph (Figure 1) will be a straight line if the infection spread is continuing to increase exponentially. While the curve may seem to depart from the straight line, recent data suggest that its trend is closer to a straight line than curving downwards. A proper statistical regression analysis to the data will show that the best curve that fits the data in this graph is a straight line.

Another way of looking at this trend, as discussed in an earlier article (“Lockdown and after”, Frontline, May 8), is the “growth factor”, the ratio of the changes in the number of confirmed cases between two consecutive days. If one looks at the data for the past one week (Figure 2) from May 1, this growth factor, though close to 1, has been mostly above 1. This implies that although the growth rate is close to dropping below the exponential phase, it is still very much in that phase even as the country is into its third consecutive lockdown.

While at the individual level some States have done well and succeeded in veering off the exponential phase, there are, as can be seen from Figure 3 (where both the increase in the number of cases and the total count are plotted on a log scale), still a significant number of States that are in the exponential phase (closer to the reference straight line), and the growth rates there are a source of concern. These States are Maharashtra, Gujarat, Delhi, Tamil Nadu, Punjab and West Bengal, with the last three experiencing a sudden spurt in cases. The trend at the all-India level basically reflects these worrying State-level trends. Comparison of these States with States such as Kerala and Telangana is particularly telling. Of course, one must add here that one is taking the data at face value, which may not be the true picture because of State-level disparities in testing rates.

The case timelines of some of these problem States are shown in Figure 4a. As can be seen, compared with Kerala and Telangana, where the number of cases has levelled off, Maharashtra, Gujarat, Delhi, Punjab, Tamil Nadu and West Bengal have seen a recent large increase in the number of cases. In Figure 4b the increase every day (measured in a certain way to smoothen out fluctuations) is plotted against the total count on that day and tells one how close to or distant from “dropping off” the exponential phase a State is. Whereas Kerala and Telangana have deviated substantially from the reference straight line that indicates exponential growth, the problem States are still close to the straight line, which indicates that they are still very much in the exponential phase and are quite far from dropping off any time soon. While Maharashtra, Gujarat and Delhi have experienced a steady large growth in the number of cases, in the case of Punjab, Tamil Nadu and West Bengal a sudden massive spurt in numbers has resulted in their case timelines now curving back towards the exponential reference line after earlier showing signs of dropping off from it.

One of the metrics the government uses to depict the effectiveness of the non-pharmaceutical interventions it has enforced, such as lockdowns, restrictions on movement and physical distancing, is the so-called doubling time (DT). This is the time taken for the number of infections on a given day to become double that figure. Equivalently, given the number of total cases on any given day, the DT is the number of days prior to that when the number of cases was half that value. It is easy to understand that a higher DT means that the infection spread is slower and, conversely, a lower DT means it is spreading faster. If measures taken to contain the spread have been effective, then the DT will increase. Since May 1, the national-level DT has been slightly above 11 days. Of course, because of highly inadequate testing, this data may also not reflect the true picture.

Compared with the national figure of 11, Kerala’s DT has been showing a steady increase since the last week of March, and from a value of 5 days then, its current DT is about 37! Telangana’s DT is around 24 days, which is also praiseworthy. The DTs of the problem States are as follows: The DT in both Maharashtra and Gujarat, with their steady increase in the number of cases, has been around 9.5 for some days now. From 13 days, Delhi’s DT dropped to about 10.5 between May 1 and May 7. Punjab’s DT, which was around 16.5 at the end of April, suddenly dropped to under 1 with the huge increase of 105 (out of a total of 480) cases in just one day after positive cases were found in a large number of pilgrims returning from Nanded, Maharashtra. As of May 7, it has inched back to about 5. From a DT of about 11, West Bengal has now dropped to less than 9 days, which reflects a spike in the number of cases. According to the State government, this is due to greatly ramped-up testing. Tamil Nadu’s DT was around 17 at end of April but now has dropped to about 5, reportedly because of the government’s failure to test truck drivers and other workers coming into Tamil Nadu from other States. The government, on the other hand, has maintained that the increase in number is due to increased testing.

According to the Union Ministry of Health and Family Welfare (MoHFW), 20 districts accounted for 68 per cent of the active cases in the country. In particular, the DTs in eight districts were faster than 10 days: Mumbai, Ahmedabad, Chennai, Central Delhi, North Delhi, Kolkata, Kanpur Nagar (the urban Kanpur district) and Krishna (Andhra Pradesh). The top 20 districts accounted for 72 per cent of deaths, and in seven districts—Mumbai, Ahmedabad, Indore (Madhya Pradesh), Pune, Surat, Central Delhi and Krishna—the case fatality rate (CFR), or number of deaths divided by the number of confirmed cases, was higher than the all-India average of 3.2 per cent. Nine districts had confirmation rates higher than twice the all-India average of 4.4 per cent of numbers tested. The overall testing rate in the country, however, continues to be low, about 1,100 per million. More importantly, nine of the top 20 districts are short on infrastructure, according to the MoHFW.

Having initially failed in a major way to undertake broad-based testing across the country and the associated measures of contact tracing and isolation and concerned about the worrisome trend in disease prevalence and its growth in many parts of the country, the Centre now seems to be trying to find scapegoats for the continuing rise in the number of cases. It has begun to blame the States and people for the situation. In a videoconference with State governments, the MoHFW stated that the higher doubling rate (or lower DT) was because States were not strictly enforcing lockdown measures or carrying out active contact tracing or active case searches and because people were neither following physical distancing and other voluntary measures nor strictly observing home quarantine and isolation guidelines.

On the high CFR in some districts, the Ministry said that people had poor knowledge of symptoms, and it blamed States for not doing enough to spread community awareness through their Information, Education and Communication programmes. It has now, belatedly, asked the States to increase the sampling rate for testing purposes.

The MoHFW also seems to believe that the health-seeking behaviour of people left a lot to be desired as there was hesitancy and delayed reporting of symptoms at health care centres. Union Health Minister Harsh Vardhan reiterated this point on May 6, 7 and 8 when he had videoconferences with different State Health Ministers.

The Centre also seemed to find fault with health care factors by stating that the higher CFR could be because health care facilities were not following standard treatment protocols. It acknowledged that there was not enough health care staff or adequate infrastructure and supplies at many State health care facilities. To address the lack of staff in the critical high CFR districts, the MoHFW has advised States to mobilise staff from different sources, including from adjacent districts, engage private doctors on contractual basis and explore the possibility of engaging retired professionals, final year students, members of non-governmental organisations, and so on. As regards infrastructure and supplies, it has asked health care facilities to mobilise material resources from adjacent districts and raise demand requests to both the State and Central Health Ministries. These, clearly, are more easily said than done.

Some of the above issues are a direct fallout of the Ministry failing to take adequate steps to ensure State-level preparedness in December-January itself when it was clear that the rapid spread of COVID-19 in the country was imminent and inevitable. Even though health is a State subject, the Centre should have given States the support of necessary funds and resources to get prepared, including in training health care staff adequately. Besides, this is also evidence of the lack of proper communication between the Centre and the States. It is unrealistic to expect States to get into firefighting mode to handle the crisis and that too when they have inadequate resources at their disposal.

It is clear that all these observations about States by the Union Health Ministry are a direct fallout of the years of neglect of the health sector, the grossly inadequate Union health budget and poor Centre-State relations on the financial front, which prevents States from being able to budget adequately to improve health infrastructure and human resource at the State level. As rising graphs of the number of cases in problem States continue to hug the exponential curve and COVID-19 continues to take its toll, it should be clear to the government that brute-force measures and diktats from the top such as lockdowns will not solve the problem as long as there is no long-term vision on health at the Central executive level. According to reliable sources, decisions on the second and third phases of the lockdown seemed to come directly from the higher executive without any scientific inputs of the key health advisory groups, including the National Task Force on COVID-19 and the Epidemiology and Surveillance Group of the Indian Council of Medical Research. Ad hoc measures not based on science and medical research are clearly not the rational way to fight a major epidemic.

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