On June 1, while briefing the media, the Joint Secretary (Health), Lav Agarwal, presented several PowerPoint graphs showing how India’s handling of the COVID-19 pandemic was on a par with, if not better than, many countries vis-a-vis mortality and recovery rates. This was on a day when the number of new cases in the country had crossed 8,500 and the total number of infections was over two lakh. Between June 3 and 4, another 9,500 infections were reported from across the States. “We are in a lock to unlock situation now,” he said, expressing optimism. He also screened a video with a popular star, a brand ambassador of sorts for the government’s sanitation campaigns, sharing a message that it was safe to step out, but with a mask on.
Another message that was relayed with theatrical effect was that there was no need to fear and the government had made all the arrangements in case anyone contracted the virus. All in all, it sought to convey a sense of normalcy that was clearly missing on the ground.
Agarwal also offered nuggets of advice to the elderly and those who had other illnesses: “Stay at home, maintain social distancing from relatives who might have to step out, keep yourselves engaged with yoga, intellectual stimulation and consult a doctor if you feel unwell.” But there was nothing on the specific steps the government was taking to help those in the vulnerable age group—many of whom might not have comfortable family environments or even families around them—if they were infected. Agarwal also recommended “immunity boosters” such as “kaadha” and herbal tea as advised by the Ministry of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy). He assured everyone that the various measures taken for surveillance, clinical management, contact tracing and boosting the health infrastructure would keep the spread under control. The message was loud and clear: that people would have to learn to live with the virus irrespective of the spike in the number of cases and the fact that government hospitals were bursting at the seams.
Reeling off statistics, he said 95,527 people had recovered until then and that there was “steady improvement” in recoveries. He said “the analysis that India ranked number seven among countries with the largest number of cases was doubtful” and added that India’s situation should be compared with countries with similar populations. “Our case fatality rate is among the lowest in the world,” he said. Ten per cent of the population (60 and above) had contributed to 50 per cent of the deaths among the confirmed cases, he said.
ICMR’s statistics
As if in a bid to underscore the “atmanirbhar” (self-reliance) motto, a catchy phrase the Prime Minister recently introduced, an official from the Indian Council of Medical Research (ICMR) said the government was testing more using indigenous capabilities. The ICMR representative said there were 476 government laboratories and 205 private ones. From 20,000-25,000 samples a day in the end of March testing had gone up to 1,20,000 on an average every day, she said.
She also said that indigenous platforms such as “TrueNat” (used for TB testing in district laboratories) were being encouraged for screening and confirmatory tests. Its “availability,” she said, was “high” at district and primary centres. On May 19, the ICMR issued revised guidelines for TrueNat testing, which, it said, was a comprehensive “assay” for screening and confirmation of COVID-19 cases. Apparently, the biosafety requirements in this test were fewer and handling concerns were limited. Many TrueNat machines had been ordered and indigenous RNA extraction kits were also available, the ICMR spokesperson said. There were around 11-12 Indian vendors whose RT-PCR (reverse transcription-polymerase chain reaction) test kits were being used. “Today we are in a much more comfortable stage,” she said, adding that “our situation has eased out” in terms of testing.
In fact, compared with other countries, India’s epidemic control strategy built around an unplanned lockdown can by no means be called successful (even if one ignores the issue of lower testing numbers per capita). The truth is that the pandemic exhibits a certain pattern in its worldwide spread, in relation to which the Indian story hardly stands out as an exemplar.
Economically advanced countries of western Europe and North America, with barely a tenth of the world’s population, were hit hard initially. The pattern of the pandemic spread was indicative of some relationship with per capita income levels of countries, with poorer countries getting less affected. What was seen in China’s Hubei province, the first pandemic epicentre, was not repeated across this vast and heavily populated region, including in the rest of China. East and South East Asia have also not been part of the more recent trend of the pandemic spread in regions other than the West.
South Asia and Africa, despite still having relatively low per capita incidences of cases and deaths, have been part of this trend though; the number of cases here has crossed East Asian levels. With the late onset of the epidemic in these places, they continue to be behind many other parts of the world, including the rest of Asia, on the epidemic curve.
Thus, the Indian story so far has been broadly determined by geography, economic status and, a large extent, demographic characteristics like a young population. If one were to consider the Health Ministry official’s lament that India should be compared with countries having similar populations, in per capita terms, the Indian situation is almost identical to that of the African continent which has almost the same population size as India. The epidemic explosion in India, however, has been faster than in Africa as a whole. On April 30, Africa’s 39,707 cases and 1,638 deaths were more than the corresponding figures for India, that is, 34,862 and 1,154, respectively. However, by mid May the situation reversed and by the end of the month the number of cases and deaths in India were 28 per cent more than in Africa.
During the lockdown, India was behind 36 countries in terms of the number of infections. At one point it had the highest number of cases in Asia; only Russia’s count crossed India’s. As on May 31, among 212 countries (covered in the Worldometers data base), 119 had a lower percentage of deaths/cases than India; 69 countries had fewer cases per million population and 89 countries fewer deaths per million population. In all these three indicators, 40 countries had lower levels than India. Of these, 17 had done more tests per million population than India. These included Venezuela and Paraguay from South America; Bhutan, Nepal and Sri Lanka from South Asia; Thailand, Taiwan and Vietnam from East and South East Asia; and Rwanda and Zimbabwe from Africa.
‘Shifting strategies’
Not many people believe that the government has done enough. In April, 16 eminent public health experts from the Indian Public Health Association (IPHA), the Indian Association of Preventive and Social Medicine and the Indian Association of Epidemiologists formed a joint task force to advise the Prime Minister on a containment strategy. The team’s terms of reference were to review and collate the scientific epidemiological literature pertaining to COVID-19 at the national, State and district level; develop a consensus among experts on disease epidemiology and its trends and develop an action plan based on the consensus; disseminate the consensus statement and action plan among public health experts and other stakeholders; and share it with policymakers at the highest levels.
According to Dr Sanjay K. Rai, president of the IPHA, the 16 experts came together and gave a written consent to be part of such a joint effort. The task force submitted its suggestions to the government twice, once in April and then in May. One member of the task force was part of the national task force set up by the government and another was the member of a subgroup on COVID-related research and epidemiology set up by the ICMR. “We did not release our statements publicly. We submitted our recommendations to the Prime Minister, Health Ministry and to our members,” Dr Rai told Frontline . The recommendations included increasing India’s expenditure on health to 5 per cent of the GDP.
The task force reviewed all evidences, globally and nationally, and concluded that living with the virus was the only way out and that strategies should now move from containment to mitigation.
COVID-19 had worsened health inequities and public health interventions were needed to address this, the task force said. Despite a very stringent lockdown strategy, the number of cases had increased exponentially, it said. From 606 infections on March 25 the number of cases had increased to 1,38,845 on May 24, that is, 229 times in two months.
The task force’s statement faulted the government on consulting an institution that produced a model with the worst-case scenario while ignoring epidemiologists who had a better idea of disease transmission. The “incoherent and often rapidly shifting strategies and policies” were a reflection of an “afterthought” and a “catching up” phenomenon, the statement said.
The task force also stated that the “returning migrants” were taking the infection to every corner of the country, the rural and peri-urban areas, which had mostly weak health systems. It said that most of the cases did not require hospitalisation and could be treated at a “domiciliary level”, managed at home with “social distancing”. The first joint statement submitted on April 11 recommended that the lockdown be lifted with domiciliary treatment. But the government ignored it. As cases continued and the government realised that the lockdown was unsustainable, it came around to accepting the suggestion of domiciliary treatment.
On May 25, the task force members reiterated most of the recommendations that were made in their first statement. They recommended the lifting of the lockdown with cluster-specific restrictions based on an epidemiological assessment and urged the government to constitute an interdisciplinary panel of public health and preventive health experts and social scientists at the Central, State and district levels to address both the public health and humanitarian crises. They argued for more data transparency, urging that all data should be made available in the public domain.
They also demanded the restoration of all routine health services, surveillance of Severe Acute Respiratory Illness and Influenza Like Illnesses by front-line health workers as well as in clinical institutions, including private hospitals. Testing should be stepped up, they said, and the government should use the existing HIV serological surveillance platforms which would be cost-effective as well.
When it is a known fact that there is no treatment for COVID-19 and that only supportive treatment and care are possible, the government has been extremely reticent in sharing information on treatment protocols or even the country’s own involvement in the international Solidarity Trials involving 400 hospitals in 35 countries. Even as the last word on the malarial drug Hydroxychloroquine as a form of treatment for COVID is yet to be had, a fresh controversy erupted over the authenticity of a study. The Indian medical establishment has been hardly forthright on the number of clinical trials under way in the country and the identity of the entities conducting them. Meanwhile, a home-grown outfit that specialises in Ayurveda products and has international reach claimed to have received permission from the Drug Controller General of India (DCGI) to do clinical trials for a cure for COVID-19. This company has reportedly received permission to conduct such trials in a private medical institute in Jaipur, Rajasthan. ICMR sources told Frontline that it had not given permission for clinical trials claiming cures by “pathys”, a generic term for the AYUSH stream of medicines. The permission, the senior scientist said, must have been given either by the AYUSH Ministry or by the DCGI. The DCGI did not respond to Frontline ’s queries. Online queries sent to the Ministry of Health and Family Welfare on this particular issue also elicited no response.
Lack of transparency
It is this lack of transparency that has raised more questions than answers on all fronts. Amulya Nidhi, a public health activist associated with the Jan Swasthya Abhiyan (People’s Health Movement), told Frontline how COVID data on recovery rates were being fudged. On June 1, the Madhya Pradesh government publicly lauded the efforts of a private hospital, Chirayu Hospital, which claimed to have discharged 1,000 COVID patients, a first in India. Amulya Nidhi and his team scrutinised the discharge data of the hospital from April 18 onwards when its first patient was discharged and found that until June 1, it added up to 976 only. The same day, the State health bulletin showed that 963 patients had been discharged in Bhopal district. Between them, the All India Institute of Medical Sciences (AIIMS), Bhopal, the Gandhi Medical College Hospital and the Homeopathy Medical College had discharged 225 COVID patients. That left a remainder of 738. “This is a clear case of data manipulation,” he said.
To date, there has been no uniformity of structure or data in COVID bulletins issued by State governments. While some States such as Maharashtra, Kerala and Tamil Nadu issue daily bulletins, others were sparing in letting out information. The Uttar Pradesh government’s COVID bulletin is inaccessible, requiring as it does a special login for the Directorate of Medical and Health Services. The Congress-led Rajasthan has in its bulletin a separate category for migrants who had tested positive. This is almost like the categorisation done by some States initially in their COVID-19 bulletins for those who had attended the Tablighi Jamaat event in Delhi and who were branded as virus carriers after some of them tested positive.
The “opening up” of the economy is proving to be a bigger challenge than the lockdown itself, which was the easiest option for the Central government. In an area on the Delhi-Uttar Pradesh border that was declared a containment zone by the Uttar Pradesh government, kiosks and other material left behind by migrant workers were used to barricade the containment area. Such has been the level of precaution and preparation by some State governments for the “lock to unlock” process.
Unfortunately, the Narendra Modi-led dispensation does not want to admit what a colossal failure the lockdown has been in terms of economic costs and livelihoods lost. The low case fatality rate can be a thing to harp on, but the question is for how long.
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