“Only one country in the world has tested more than us,” stated Union Health Secretary Rajesh Bhushan at a press conference on September 3. He did not specify the country but was alluding to the United States. He also stated with unconcealed pride that India had conducted over 11 lakh tests in the previous 24 hours. What was unsaid and went totally ignored in the press conference was that the daily spike in cases had crossed 80,000 on at least two days, making India the nation to report the largest single-day spike so far or that India was inching towards replacing Brazil as the number two nation with the largest number of COVID-19 cases.
Rajesh Bhushan also said that 29,70,492 people had recovered; this, however, was the cumulative figure since March. He said that the recoveries were three times the number of “active” cases. But he did not clarify that the figure for recoveries was the cumulative number, while the 8,15,538 active cases that he mentioned referred to patients who were currently infected.
Nearly 62 per cent of the active cases were from Maharashtra, Andhra Pradesh, Tamil Nadu, Uttar Pradesh and Karnataka. The five States accounting for 70 per cent of deaths were Maharashtra, Andhra Pradesh, Tamil Nadu, Delhi and Karnataka.
When media persons expressed concern about the surging cases, Rajesh Bhushan said that the rationale behind “Unlock 4.0” was that “while lives had to be saved, livelihoods also were important”. He had little to add about the government’s plan to restore livelihoods that had been lost over the last five months, which also saw many people coping with salary cuts.
It is notable that irrespective of the visible threat posed by growing infection, especially in August, the Health Ministry went along with the directive of the Home Ministry and the University Grants Commission to educational institutions to conduct examinations, offline and online, for terminal semester students by the end of September.
India currently has the third largest number of cumulative COVID-19 cases, 3.93 million, and appears destined to go up one place by crossing Brazil’s tally in a short while. Its total now exceeds the aggregate for the entire continent of Europe as well as that of the whole of Asia other than India and is over three times the reported figures of the African continent. India has also the third largest number of deaths (68,000) attributed to the pandemic among all countries, having crossed Mexico’s tally recently.
The government’s argument was that as India’s population was bigger, the number of cases was also on the higher side. However, no comparison at any stage was ever made with China, which is similarly populated and where the cumulative number of COVID cases (85,077 as per Worldometers) now is equal to the daily number of cases reported in India.
Testing rates
In a self-congratulatory tweet on September 4, the Health Ministry said: “India continues to scale new peaks in COVID-19 tests! More than 11.7 lakh samples tested daily for two consecutive days. No other country has achieved these levels of very high testing. Even with such high daily testing levels, daily positivity rate is less than 8.5 per cent. This reflects that the Centre led strategy of Test-Track-Treat is being effectively implemented by the States and Union Territories.”
Yet, the facts tell a different story. In several countries with smaller populations, the number of tests per million population exceeded India’s. In China, which has a population comparable to that of India, 111,163 tests per million had been conducted against 32,922 in India. The total number of tests in China amounted to 16,00,00,000 against 4.5 crore in India. This was despite the fact that COVID-19 deaths in China were fewer than 5,000 (4,634, according to Worldometers), whereas India’s death toll has crossed 68,000.
According to the government’s own data. testing rates picked up only in August. From 10,000 tests in April, the number went up to 10 lakh in May and 50 lakh in June. It was clear that had the government gone in for aggressive testing right from the beginning, the spread would have been contained.
There has also been reasonable scepticism about the antigen tests that now comprise a good 30-40 per cent of the total samples tested. Compared to the gold standard RTPCR tests, antigen tests are less accurate.
The claim that the number of active cases had reduced in some of the worst affected States was also not accurate as the total number of active cases far exceeded the number of recoveries in those States. Characteristically, the government did not reveal the extent of the spread of the infection to newer areas.
The government has from the very beginning sought to play down the inadequacies of the health infrastructure and the prevalence of community transmission of the virus.
It has also not revealed so far how other health services have been adversely affected as much of government health infrastructure had been diverted for treating COVID and related morbidities.
The August surge
August has been a grim month for India. Almost two million new cases were detected, which made up 54.1 per cent of India’s cumulative total by the end of August. Within this one month, both the one and two million levels were crossed and then almost 70 per cent of the additional distance to the four million mark was also travelled. Since the proportion of tests done in August was also at 55.1 per cent of the total done since the beginning, it can be said that testing has kept pace with the growth of the infection and greater testing is not the reason for larger numbers, as claimed by the government. The overall test-positivity ratio has remained within the 8.5-9 per cent range over the month, and this is despite the rising proportion of the less accurate rapid antigen testing in India. Even with respect to deaths, which are less influenced by testing, August presented a bleak picture: the close to 29,000 deaths in the month accounted for 44.1 per cent of the cumulative total. In other words, the country ended up experiencing in August almost exactly what it had gone through cumulatively in the previous six months. Rajesh Bhushan’s claim at the Health Ministry’s press conference that the death rate at 49 deaths per million was among the lowest in the world was also not correct.
The news in the first three days of September brought no cheer as India shattered once again the world record for the largest number of cases reported by any country in a single day, breaking the record set by itself towards the end of August. As compared with the previous highest single-day figure in the Health Ministry data of 78,761 cases reported on the morning of August 30, September saw 78,357 fresh cases being reported for the first day of the month and then a whopping 83,833 on the next. This was almost repeated on the third day when 83,341 cases were reported.
India’s COVID growth much faster
India’s August picture does not reflect a global surge as its cases of infection and deaths have grown much faster than the world average. India’s share in the world’s total of confirmed cases rose from 9.4 per cent to 14.4 per cent over the month and that in deaths went from 5.4 to 7.7 per cent (Worldometers data). If the situation in August alone is considered, India has contributed the highest number of cases to the world’s tally, well ahead of both the U.S. and Brazil, and almost matched these two countries in contribution to global deaths during the same period (see table).
India’s surging numbers have meant that its per capita counts of cases and deaths have been among the fastest rising in the world. (These were relatively low in the early stages of the pandemic because of the late onset of the epidemic in the world’s second most populous country.) Both the above sources, considered reliable data sources, indicate that more countries in the world now have lower per capita incidences of both cases and deaths. Even more significantly, while this set of countries with lower per capita levels of cases and deaths than India’s are spread across all continents, they include almost all countries in East, South East and South Asia, even Bangladesh, Pakistan and Nepal. India is truly a standout case in a negative sense after geography, demographics and economic status are all accounted for. So much, then, for the official claim that India’s per capita figures are among the lowest in the world—which appears to be a blatant misrepresentation of the facts.
The myth of “high recovery” rates
Of late much is being made of the large number of recoveries and the low fatality rate in India. However, a large number of recoveries, or a rapid growth in the number of recoveries, basically reflects with a lag the number and growth of confirmed cases, since most people infected do ultimately recover within 10-11 days of being tested positive (and this period is shorter if the infection is detected at a later stage.) Thus, while the number of recovered patients increased by about 1.74 million over the month of August, the number of confirmed cases in a period of identical duration up to August 22 was to the order of 1.78 million. It is odd, therefore, to see this failure to check the spread of the infection being claimed as some great achievement. The point that is missed is the large spread of COVID-19 in India, which is what the large number of recoveries indirectly imply. Thus, in the month of August, despite the rise in the number of recoveries, the number of active cases continued to rise—to almost eight lakh by the end of the month compared with 5.65 lakh at the beginning. Moreover, even with a declining trend in the case fatality ratio (CFR), the number of deaths is already large and is becoming larger.
CFR patterns similar
Fatality ratios in any case have tended to come down the world over with increasing experience of dealing with COVID-19 patients and with a rising proportion of younger people getting infected. This is true even in the high-income Western economies where fatality ratios tended to be the highest in the early months of the pandemic. Thus, even in the U.S., which accounts for the largest number of deaths in the world, the fatality ratio during its second wave has been much lower than in the first. Between June 25 and August 31, the U.S. added over 3.70 million to its total tally of cases and just about 60,000 to its death toll (data from Worldometers). Compare this with India’s total of 3.69 million cases and over 65,000 deaths by the end of August—keeping in mind that 87 per cent of this total of cases and 77 per cent of the deaths were in the period after June 25.
At a video conference with the Chief Ministers of the 10 most badly affected States on August 11, Prime Minister Narendra Modi said that the target of reducing the fatality ratio to 1 per cent could be achieved. The fatality ratio is the ratio (percentage) of deaths of infected people to the total number of confirmed cases of infection. Since over 68,000 deaths have already been recorded, a fatality ratio of 1 per cent would be impossible to attain unless the number of cases is at least 6.8 million (since 68,000 is 1 per cent of 6.8 million). However, even if a progressively smaller proportion of infected people die in the days ahead, the number of deaths will go up significantly by the time the cases increase from the present 3.93 million to 6.8 million. In other words, the fatality ratio would still be above 1 per cent and the process would need to go on further to reduce the ratio to the 1 per cent level. So, for the Prime Minister’s target to be achieved, the total number of confirmed cases will perhaps have to top at least 10 million. Is that what is in store for the country?
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