Among the many things that stand out in the national strategy to deal with the second wave of COVID-19 is the swift shift to exhibiting an air of optimism in the government’s recent media briefings. Spokespersons of the Health Ministry and the NITI Aayog have been quick to declare that the second wave is “on the downswing” and the situation is “stabilising” in large parts of the country. On offer is a series of numbers that are designed to inspire confidence. Phrases like “steady decline in daily cases”, “progressive decrease in districts reporting high cases”, “continuous decrease in active cases”, “recoveries exceeding the daily cases reported”, “consistent increase in recovery rate”, “continuous increase in testing”, “steady decline in case positivity” and “over 20 crore vaccine doses administered” are designed to make headline news. Much of this is a repeat of what was said when the first wave was waning after peaking in September 2020.
One might have thought that the devastating second wave would serve as a humbling experience and lead to the realisation that there are other numbers which might be more important and that some of these important numbers are simply not available. A senior pulmonologist who is part of the government’s task force had told the media in one of the earlier briefings that many respiratory infections came in waves and that it was necessary to ensure that the effects of another wave were mitigated.
It is also being asserted now that the pattern of infection was the same as that experienced in the first wave, even though it is well known that variants of the virus have been responsible for the sharp spurt in cases and faster progression of the infection within the body. The way in which rural areas have taken a hit in the second wave has exposed the limitations of the health care system.
The headlines put out by the government simply capture the fact that going by data for the three-week period subsequent to May 6 , it may be said that the second wave reached a crest on that day when 4.14 lakh new cases were reported. However, what those trends do not reveal is that in that period India reported over six million cases and close to 85,000 officially acknowledged COVID deaths. These are more cases and more deaths than were seen in the period from January 30, 2020, when the first confirmed case in India was reported, to September 16, 2020. India remains by a long stretch the country contributing the largest numbers to global COVID cases and deaths, accounting for 41 per cent and 35 per cent of the respective world totals in the seven-day period ending on May 27. And this in a situation where lockdown restrictions are in force in several parts of the country.
There were 7.2 million cases reported in the three weeks leading up to May 6 against the six million plus cases reported in the three weeks after May 6. However, the deaths reported in the three weeks after May 6 are significantly higher than the 59,775 reported in the three weeks ending on May 6. Though there is a downward trend in cases, the average number of daily deaths is yet to show a decline. In the two weeks after the seven-day average of daily deaths crossed 4,000 for the first time on May 11, the figure has tended to stay around or above that level. On May 18, there were 4,529 deaths, the highest daily number of deaths to occur so far in a single day. The cumulative count of the deceased has gone well past the three-lakh mark.
Perturbed by adverse publicity
Instead of being bothered about the high casualties, the Union government has shown itself to be more perturbed by the adverse publicity in sections of the international media, which have alluded to an undercounting of deaths in India. A recent report in TheNew York Times (“Just How Big Could India’s Covid Toll Be”, May 25, 2021) on estimated infections based on three already conducted sero-surveys and quoting a dozen experts came up for particular criticism in an official media briefing. The government felt that the report was based on cherry-picked data. In fact, the World Health Organisation has also stated that the death toll globally could be two or three times higher than what has been reported. It said that the official toll of deaths could be a “significant undercount” though it did not name any country. The NYT report also suggested that even in countries with robust surveillance, the number of infections could be higher as many had not got themselves tested.
The Health Ministry’s response was sharp. “They have used our serology data. The estimates are distorted. Five experts sit together and have an online meeting. We don’t accept this. We have a strong data tracking system,” said V.K. Paul, NITI Aayog member and chair of the National Task Force on COVID-19, while addressing the media on May 27. He also said that reported cases were always a fraction of total infections in any country. The joint secretary, Lav Agrawal, seemed petulant. He said the report was false, baseless and not supported by evidence. He said that there was a system of registering births and deaths and that the question of deaths being “hidden” did not arise.
Almost every expert, whether at home or abroad, is convinced that India’s official COVID death toll is a gross underestimation and that a realistic assessment of the numbers is important for fighting the pandemic effectively. Apart from the NYT article, several media stories from different parts of the country have demonstrated that there has been widespread undercounting of fatalities. Several expert estimations have put the true figure to be many times the official figure. Yet, there is no official acknowledgement of the fact that government data have obliterated the deaths of lakhs of citizens. There is no effort on the part of the government to use the data and information, which it can make available to researchers, to arrive at a more accurate estimate of the death toll. In this context, it becomes meaningless to talk about the case fatality rate or recoveries. More important than talking about the recovery rate improving is what is not being said—that even the official death toll cannot conceal the fact that in the second wave deaths ultimately rose faster than confirmed cases. This means that the case fatality rate actually increased and is yet to return to the levels seen in early February.
Issues with testing rates
The government claims that testing rates have touched an all-time high of over 20 lakh. However, it was only in the third week of May that testing numbers crossed this figure. Daily tests numbered below 10 lakh each day for most of February and until the first week of March, after which it began picking up. However, even in the week in which the cases peaked, the daily average of tests was just over 17 lakh, much below the total testing capacity declared by the task force. The test positivity rate, which was in the range of 2 per cent in the second and third weeks of February, shot up to 22.35 per cent on May 7. Although it declined to 10.45 per cent on May 27, it remains close to the maximum levels seen in 2020.
The increase in testing numbers after the peak was crossed seems to give substance to reports that the authorities in several parts of the country deliberately suppressed the number of tests in order to keep the COVID figures low. On May 20, Health Ministry officials declared that testing would be stepped up massively with more Rapid Antigen Tests (RAT) for early detection and that RTPCR tests had been “rationalised” in the second wave. The logic of pushing for the less reliable RAT method was not clear unless a continuing shortage of RTPCR test kits in the country was anticipated. In any case, the stated capacity of the RAT method (17 lakh tests a day) was far more than the RTPCR test capacity at 12 lakh a day. The RAT modality, it was said, would be used for testing in rural areas in primary health centres, community health centres and sub centres.
The Indian Council of Medical Research (ICMR), the media were told, had approved more companies for the RAT method of testing. The media were informed that test kits priced at Rs.250 would be available soon for people to get themselves tested at home. India was truly moving in the direction of atmanirbharta or self-reliance where the user bought the test kit, downloaded the mobile application, self-conducted the test and uploaded the results in the application on the phone. The government aimed to reach a target of 25 lakh tests a day by the end of May and cross 45 lakh tests a day in June. It was as if the government had suddenly woken up to the importance of conducting tests. Increasing testing after the peak and placing greater reliance on RAT tests help to present a picture of decline in test positivity rate that is rosier than what the reality warrants.
Vaccination slows down
There has been considerable chest-thumping about the fact that after the United States, India was the only country to have crossed the 20 crore vaccination dosages landmark and that 42 per cent of the population above 60 had received one dose of the vaccine. Yet, what does it really mean in relation to combating the pandemic? The government said on May 27 that 15.6 crore people had received at least one vaccine dose; this number constitutes less than18 per cent of the adult Indian population. Those who have received both the doses do not make up even 5 per cent of the adult population. What makes the comparison with the U.S. specious is that the U.S. has already fully vaccinated more than 50 per cent of its adult population. At 14.38 doses administered per 100 of the population as of May 26, India was well below the world average of 22.79 per cent. The figures of China and Brazil, at 39.37 per cent and 30.38 per cent respectively, are far ahead of India’s.
The 18 per cent of the adult population that has received at least one vaccine dose in India are still less than the third serosurvey (December 2020-January 2021) estimate of 21.5 per cent carrying antibodies because of exposure to the infection. We do not know how much that percentage has changed as a result of the massive second wave in which the total number of cases so far is 1.7 times the number reported until the end of January. However, it can perhaps be confidently said that the virus is still way ahead in the race with vaccination. The vaccination drive has slowed down along with the decline in daily cases—the number of vaccine doses administered in India in the three-week period after May 6, at around four crore, is only four-fifths of the over five crore doses administered in the preceding three week period. It is now clear that the 7.3 core vaccine doses the government had earlier claimed would be available in May will not materialise: less than five crore people got the vaccine until May 27. The continuing flip-flop in vaccination policy makes a coherent and stable policy unlikely anytime soon.
To add to the country’s woes is the growing menace of Black Fungus infections among those who have recovered from COVID, and here India appears to account for 70 per cent of cases reported globally. In a repeat of the crisis with oxygen and other drugs, medicines to treat this infection are in short supply. Officials tend to blame indiscriminate use of steroids for this new problem. What is not acknowledged is that ultimately the problem resulted from the health system being overwhelmed and thousands of patients being unable to access proper medical care. It is not, therefore, a separate problem or a side effect but an additional dimension of India’s COVID crisis.
The one consistent feature about the national strategy to deal with the second wave is the lack of consistency and clarity in approach. Even as the Central government would have the nation believe that knowledge around the virus is relatively new and that the scientific establishment is still learning about the evolution of the virus, including its tendency to mutate, the constant flip-flop even in therapeutic strategies has ended up creating more confusion than clarity.
There also seems to be a distinct lack of coordination in scientific data-sharing, besides the opaqueness in the sharing of mortality and morbidity data since the onset of the second wave. On May 19, for instance, the National Task Force on COVID issued an order removing Convalescent Plasma Therapy from the Clinical Management Protocol for adult patients with COVID. This was interesting as it took one whole year for the NTF to come to this conclusion. The order replaced the public notice issued by the Central Drugs Standard Control Organisation on July 1, 2020, which had listed plasma therapy among the investigational therapies for COVID treatment.
The COVID crisis in India, both the present situation and the potential future one, therefore, remains big. Unfortunately, it seems that the same error of the government privileging perception management over real management is coming to the fore and hampering efforts to deal with the pandemic. It does not appear likely that the crisis will ease anytime soon, even if there is some temporary reprieve.