Covid-19 has begun to inflict itself on India’s large and susceptible population. What needs to be done?
We need to accept that we are simply not testing enough. A lot will also hinge on whether the govt can, in these three weeks, better prepare its hospitals and procure enough ventilators
The situation is grim and is getting worse by the day. While the government is bravely talking of its 21-day target to tide over the covid-19 crisis, it is by now clear that we may be looking at a best-case scenario of at least 3 months of misery, isolation and recession and a worst-case of nine months.
Covid-19 has begun to inflict itself on our large and susceptible population at a faster pace than before. China’s numbers had peaked in February; March was when Iran and continental Europe were hit hard; US and UK numbers keep going up as we go into April and all indications are that May will be bad for India.
As on 30 March, India had 1,251 confirmed cases of coronavirus and 32 deaths. Some may wistfully look at these relatively low numbers and imagine that we are close to containing the problem. But actually, the trends are rather ominous. There has been a steady and consistent increase in the number of confirmed cases each day (chart 1).
The three-week lockdown is aimed at slowing the spread of the disease and is a crucial step in the right direction. Epidemiological modelling based on analyses used for countries like US and UK indicate that India could face almost 300 million cases in the next 3-4 months, of which approximately 10% could be critical cases, leading to more than 1 million deaths. Given the rise of the disease—with an exponential growth and the total number of cases doubling every 4-days—it is highly likely that the virus is spreading through community transmission, although the World Health Organization in its most recent situational report (26 March) as well as the Indian government have insisted we are not there yet.
In any case, we will indeed be lucky if we see positive cases coming down after June. Testing is still sparse, an average of 1,800 a day. We will need to increase this hundred fold to get a better grip on the situation. There is still no sign of a cure, no medicine, and no magical drug. Various untested remedies are being bandied about, including the irresponsible AYUSH ministry that as early as in January was distributing and recommending various medicines claiming they would prevent the disease. A viable vaccine may take a while. It is going to be a long haul, and 2020 may well turn out to be the year we all spent washing hands and maintaining social distance.
Given the trajectories that other countries have taken, India seems to be heading for a surge in the number of covid-19 cases as thousands of people in large groups are huddled together, waiting to be transported back home in buses and trucks. India is already home to the largest number of people with respiratory illnesses and, therefore, a very vulnerable population. To add to this, we also have more than 50 million people who suffer from diabetes and cardiovascular diseases. Therefore, the country must prepare itself for a very arduous and demanding fight against a virus that has already overwhelmed some of the most advanced healthcare systems in the world. In the one-week since the lockdown, there has been no change in the broad direction of the infection’s rate of spread (chart 2).
Hence, questions about whether the lockdown measure was taken too late or if it is even enough must be asked. Is it merely delaying the inevitable? What does the administration need to do to ensure that the lockdown provides a second window of opportunity? Which are the specific and targeted interventions that would stop transmission and help save numerous lives? And what impact would public health measures have on the economy and the agriculture sector?
The 21-day priority
Testing: We need to first acknowledge the fact that we are simply not testing enough. We need to ramp up the production, capability and availability of testing kits across the country in order to fully understand the extent of the contagion. Till 31 March, only a total of 42,788 samples have been tested. Also, states with higher populations are conducting fewer tests. West Bengal, Odisha and Andhra Pradesh have conducted only two, three and five tests per million people, respectively. Kerala, however, has conducted 137 tests per million.
Though 122 government laboratories and 44 private laboratories have been approved for testing till date, the number of tests being conducted daily are still abysmally low.
Staffing: We need a huge and immediate ramp-up of medical facilities and an increase in medical staff as Dr Devi Shetty, a well-renowned doctor, has been arguing for lately. Soon, we will have more patients who will need isolation wards, ventilators and intensive care units (ICUs). India has 2.3 ICU beds for 100,000 citizens, while Germany has 29 ICU beds, and Italy has 13. The biggest shortage, however, is by way of medical staff. Against the WHO norm of one doctor for 1,000 people, India has one for every 10,189 people. A rough calculation shows that we have a shortage of 600,000 doctors. The country also needs 2 million more nurses.
The Medical Council of India should urgently give licenses, even if they are temporary ones, to final-year medical students, to those who have graduated out of colleges in Russia, China and Turkey, and allow all students in specialist courses to start working even before they have taken their final examinations. Volunteers will need to be drafted and quickly trained to do various other duties that makeshift hospitals will need when they are set up. Like in China, what we will want to see in India is a number of new hospital beds set up by using hotels, hostels and religious places that have space, ventilation and adequate water and electricity supplies. Quick supply of piped oxygen will also convert most of these facilities into ICUs.
A lot will hinge on whether the government can, in these three weeks, better prepare its hospitals, convert a few stadiums into isolation centres, and procure as many ventilators as possible.
Relocation of migrant workers: The government also needs to roll out a reasonable plan to take all the stranded migrants back. Many are stranded at state borders, at railway stations and on highways in large groups that defeats the purpose of social distancing. It is imperative that they are safely taken back to their homes as any further delay would put them at a risk of infection. This would be a catastrophe of huge proportions as the cascade effect of the infection spreading into far-flung rural areas would be devastating.
Welfare measures: There is a desperate need for a seamless mechanism that feeds everyone across the country. The police appears to be treating a lockdown as a law and order problem and beating up anyone who ventures out, even for legitimate purposes. Most food outlets have shut shop, even when they are permitted to continue working on delivery-based orders. It is important to make everyone, especially the police, aware of what is permissible and what needs to be stopped.
90-day game plan
Research and development: It is important for India to renew its efforts in making new vaccines and discovering cures against microbial and virus attacks. Pharmaceutical firms, both in the public and the private sector, have been neglecting the need to make new vaccines against viruses. Ironically, the argument which has been made to not invest in studying viruses was the population develops immunity far too quickly for adequate returns on cures.
That is why we need far greater government investment in fighting viruses, both by way of new vaccines and through developing treatment options.
Testing: The ramp-up in testing must extend well beyond the 21-day lockdown period. Widespread testing is of the greatest importance. What we need to do over the next three months is randomized testing in densely populated urban settlements such as slums and unauthorized colonies where the infection can spread rapidly. Symptomatic testing needs to be scaled up with dissemination of information on the need for testing. Asymptomatic testing for the purpose of surveillance also needs to be carried out, especially in the case of the migrants returning home.
The government’s Working group on Migration identifies 56 districts (mainly from UP and Bihar, and the rest from West Bengal, Karnataka, Uttarakhand, Odisha, Rajasthan, Jharkhand and Maharashtra) which account for 50% of inter-state migration. The local administration should take up surveillance testing as a high priority, followed up by adequate plans on isolation and treatment of infected persons.
Health infrastructure: The next three months should also see the intensive deployment of resources into upgrading healthcare facilities. Primary health centres and wellness centres should be adequately reinforced to handle and treat mild cases of the infection. Government health spending, as we know at 1.4% of gross domestic product (GDP), is very poor but the problem is further compounded by the inadequate utilization of even the existing health budget. Less than 60% of the budget for the National Health Mission was spent and less than 40% of funds available for upgrading hospital facilities was spent in the last fiscal year.
Agriculture supply chains: Supply chains must be quickly redesigned to work around the mandis and haats where large numbers of traders usually congregate. The Telangana government has made a bold announcement. It will buy all the crops across the state and store them in empty schools. We need this in all states.
Fiscal measures: The first quarter of this year will be dismal, and the rest of the year may also be a washout on the economic front. What the government must do is to forget caution and open up the treasury. People need money, not the trivial amounts which have been announced by way of ₹500 a month for three months. What we need is real money in the hands of people, who need it to buy food and provisions, since they may well be without jobs for at least the next three months, if not the entire year.
But all of these measures will be ineffective if the public health system gets overwhelmed by May. That will be the key challenge. By reducing incidence over the course of the 21-day lockdown, India may have bought time to ramp-up preparedness. What the administration has done until now is to ask private hospitals to provide an inventory of ICU beds and ventilators and cancel all non-essential surgeries. It has also asked the private sector to not turn away suspected covid-19 patients. However, in reality, some patients are being refused admission.
It is fairly obvious that the lockdown by itself is not going to achieve everything. By reducing person-to-person contact, what we will definitely achieve is a flattening of the curve. The total area under it may still remain the same. However, a flattened curve will give our health system time to plug its loopholes and get new infrastructure in place. What we need is a sense of urgency, lots of evidence and analysis, and if possible, an occasional dose of optimism.
Amir Ullah Khan is professor of development economics at the MCRHRDI and Saleema Razvi is a senior research economist at the Copenhagen Consensus Centre