How not to handle an epidemic

The lockdowns were meant to buy time to put in place appropriate health measures and contain the coronavirus’ spread, but they have failed to achieve the objective and heaped immense misery on the marginalised sections of society. India is still in the exponential phase of the COVID-19 infection and community transmission is a reality that the government refuses to accept.

Published : May 24, 2020 07:00 IST

Health officials conducting RT-PCR tests as part of rapid testing initiative in Visakhapatnam on May 6.

Health officials conducting RT-PCR tests as part of rapid testing initiative in Visakhapatnam on May 6.

As the country enters the fourth phase of lockdown, albeit with the easing of many restrictions and opening up of some essential economic activities, it is still not out of the COVID-19 woods. With the total number of confirmed cases (as against the true number of infections) standing at 1,12,359 as of May 21, the caseload is still increasing at the rate of over 5,000 cases a day. Although the graph may appear to be showing some signs of levelling off, given the past trend, it is not certain that it may begin to decline soon.

The growth factor—the ratio of increases in caseloads on two consecutive days—has continued to remain mostly a little over 1, which means we are still in the exponential phase (Fig. 1). Of course, the national picture reflects the situation in some problem States. Barring Punjab, the other States that were discussed in the Frontline  issue dated May 22 continue to be problematic. Moreover, Madhya Pradesh and Rajasthan, whose trajectories had seemed to bend down from the exponential phase are now showing signs of trend reversal. Of serious concern will be the case of West Bengal, which will be subjected to the double whammy of COVID-19 and the supercyclone “Amphan”. The cyclone’s landfall and its continuing north-north-eastward trajectory over land, which has just passed 270 kilometres north-north-east of Kolkata into Bangladesh, with wind speeds touching 70-80 kmph, is likely to result in widespread devastation of life and property in and around that region.

Interestingly, news reports suggest that, as in the case of the previous lockdowns ( Frontline , May 22), the decision to extend the lockdown into the fourth phase was taken once again without the consensus opinion of the specially constituted National COVID-19 Task Force or other epidemiologists and medical experts. A member of the Task Force has been quoted in one of the news reports as saying that while lockdowns cut down the rate of transmission, they cannot stop transmission itself. This what the virologist T. Jacob John and the epidemiologist Jayaprakash Muliyil had told Frontline

Vinod Paul, NITI Aayog member and Chairman of the Task Force, famously claimed in his presentation to the press on April 24 that India would see no COVID-19 case after mid May. Paul has now become a laughing stock, and the country continues to stare at the growing number of infections. The only answer the government seems to have is “lockdown”. In fact, displaying utter ignorance, the Union Health Ministry’s Joint Secretary, Lav Agarwal, is reported to have said more than once at press briefings that because of the lockdowns and social distancing, cases may never peak in India. Even a schoolchild would know that this implies a never-ending outbreak. More pertinently, that is an epidemiological impossibility; the number of cases in any outbreak has to peak and then decline. According to Randeep Guleria, director of the All India Institute of Medical Sciences (AIIMS) and member of the Task Force, the peak caseload will probably be reached sometime in July. But, given the present trend, it is more likely to happen in late August. 

It has repeatedly been said that the idea of the initial lockdown (may be up to the first two phases) was to buy time to put in place appropriate health measures, including scaling up of testing with broadened testing strategy, making testing kits available, supplying masks to the general public, effective and efficient contact tracing, strengthening and building the health infrastructure with the requisite number of hospital beds (particularly intensive care units), ventilators and ECMOs (extracorporeal membrane oxygenation machines) and, most importantly, giving personal protective equipment (PPEs) for health care workers. On all fronts, the measures taken by the government have been found wanting. For example, if import and distribution of rapid antibody testing kits to the States was a major fiasco (as a result of which even to date States are running short of these kits, not to speak of reverse transcription polymerase chain reaction (RT-PCR) devices, the gold standard for testing), continuous weakening of specifications for import of ventilators by vendors and giving the contract for supply to a single supplier are nothing short of a scam.

'Make-in-India' sham

The claim of orienting the much-touted “Make-in-India” campaign to preparedness for COVID-19 has proved to be just another sham, a characteristic of the present regime at the Centre in all spheres of activity. According to sources in the Ministry of Science and Technology, government research and R&D institutions are being coerced into becoming a party to this charade. The Ministry is on an overdrive. A mediaperson is today flooded every day with releases from various institutions—channelled through the Press Information Bureau (PIB)—with claims of discoveries and inventions by these institutions and agencies. 

And to boot, the Ministry has also brought out a 156-page compendium of COVID-19-related research/R&D/products on the anvil from government research institutions, ranging from mathematical modelling to testing kits, masks, sanitisers, ventilators, vaccine and drug development and PPEs. Apparently, at 6 p.m. every day, all these institutions are required to report what has been done for COVID-19 during the day. The best sounding ones are compiled and issued as press releases that very day or the following day. 

It has been a little over five years since Ashutosh Sharma was appointed as the Secretary of the Union Ministry’s Department of Science and Technology (DST). One cannot recall him having held a single meaningful press briefing or interaction with the media discussing the department’s highlights or scientific achievements, save perhaps a couple of occasions when he appeared along with Harsh Vardhan, Union Minister of Science and Technology, Health and Family Welfare, when the latter addressed the media. But, today, every one of the PIB releases on some COVID-19-related claimed achievement of institutions under his department carries a quote from him on the achievement. But, privately, it is learnt that researchers in some institutions engaged in designing indigenous ventilators are feeling frustrated and would like to stop developing them because of the scam around its procurement. 

But what has been the outcome of these claims and their use/impact in the nation’s fight against the disease? Has any one of them made it to the field-level application or the production stage? No one knows, barring perhaps a few at best, because there has been no follow-up information about their further progression either from the developers or from the Ministry.

For example, even the “indigenous” rapid RNA extraction testing kit launched on May 21 by the Thiruvananthapuram-based Sree Chitra Tirunal Institute of Medical Sciences and Technology, an institution under the DST, sounds suspiciously similar to the work reported in a publication titled “A simple magnetic nanoparticles-based viral RNA extraction method for efficient detection of SARS-CoV-2” from the Chinese Academy of Sciences by Chinese scientists led by Zhen Zhao (and posted on on February 20). Was the near concurrent invention just a coincidence? We do not know.

While the intention here is not to judge these models or other developments by Indian scientists and question whether they are entirely indigenous or not, it is evident that the government has not made use of science inputs to impose widespread restrictions on all forms of activity, including transportation, and declare lockdowns. Did the government take the mathematical modelling seriously and plan the lockdowns and their easing accordingly? 

On the contrary, as members of the Task Force have observed in anonymity, the lockdowns have been completely arbitrary, which have only resulted in widespread misery to the marginalised in terms of loss of livelihood, extensive hunger and death. Lockdowns, as a media report quoted a member of the Task Force as saying, have been looked at by the authorities as a law and order instrument (as many images of police action have been circulated on social media) rather than a facilitator for implementing proper health measures.

Case fatality rate, a crude metric

The government earlier had been peddling the metric of doubling time as an indicator of the success of its lockdown strategy and the accompanying measures, now it has started talking of lower case fatality rate (CFR)—the crude ratio of the number of deaths to the total number of confirmed cases—than the world average. Compared with the world average of about 6 per cent (Fig. 2), India’s (crude) CFR today stands at 3.1 per cent.

Three things should be borne in mind when we look at this data and the figure. One, epidemiologically, this metric is known to be a poor indicator of the severity of the infection because there are several factors that confound the actual cause of death, like co-morbidities. Also, it is the infection fatality rate (IFR) that will give a true picture of the nature of infection. Two, the world average is skewed towards a higher value because in Italy, France and Belgium the prevailing demography, with a larger fraction of higher age groups, has played an important role in the number of deaths. Three, the CFR is low for India because its demography is in favour of the less vulnerable young population. But a more serious issue is that this metric is a crude one because deaths occurring on a given day are of infections that happened 16-18 days ago, the average time for death from the onset of symptoms. If we calculate the Indian CFR from that perspective, the more realistic CFR (though still crude) will be about 7.5 per cent. Even from this crude perspective, the CFR of India is higher than those of South Korea, New Zealand, Iceland and Vietnam (whose CFR is practically zero), where extensive testing followed by isolation, quarantine and efficient contact tracing were put into practice, and not extensive lockdowns. Community transmission

To get back to the issue of problem States, these include Maharashtra, Gujarat, Delhi, Rajasthan, Madhya Pradesh, West Bengal and Tamil Nadu (Fig. 3 and Fig. 4). Figure 4 shows graphs of daily caseload increase (plotted as a six-day moving average) against the total number of cases on that day. The reference line showing exponential increase indicates how these States are yet to move away from the exponential trend. If, as the government has maintained, the surge in these States is due to clusters in containment zones, it should share the epidemiological details of the nature of these clusters and the causes that have led to the emergence of these clusters so that appropriate State-level non-pharmaceutical intervention strategies can be evolved. It was pointed out in Frontline  (May 22) that the Centre had blamed the States for not enforcing lockdowns and adhering to testing and quarantine protocols. If that indeed had been the case, there should have been some improvement on that front, and a consequent reduction in the growth of the individual State’s caseload in the intervening fortnight. If appropriate steps had been taken in that direction, they are yet to reflect on the ground.

An earlier article ( Frontline , May 8) had discussed the emerging evidence for community transmission in the country, which was found by an Indian Council for Medical Research (ICMR)-initiated sentinel surveillance study among SARI (serious acute respiratory infection) patients across 52 districts in 20 States. Health Ministry officials continue to deny its occurrence, maintaining that only areas with clusters of positive cases showed increase in the number of cases . (This false denial, of course, gets reflected in the WHO’s situation reports as well.) 

The study had identified COVID-19 positive cases in 36 districts in 15 States with no apparent link to any identifiable source of infection. Strangely, neither the authors of the study nor the ICMR has revealed the names of the 36 districts. It is reliably learnt that the authors were specifically instructed by the powers that be to not reveal the names of the districts. But it is beyond reasonable argument or one’s understanding as to what is gained by hiding this information. 

In fact, one would have expected the testing strategy to be suitably broadened to launch widespread testing, including random testing in these districts to capture even asymptomatic cases. Even the latest revised testing strategy (Version 5 of May 18) talks of testing only asymptomatic “direct and high-risk contacts” of confirmed cases. It would be of interest to know how many of these 36 districts indicating community transmission are in the seven problematic States. But selective dissemination of information has become the norm, which is not the best way to address an evolving nationwide epidemic.


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