Beyond Mumbai and Delhi, the new hotspots in India’s corona map

India’s covid-19 case numbers are going up relentlessly and our cities have become dangerous hotspots even after a stringent lockdown. After all that has been tried and tested, the question remains the same as in January: Is there life beyond lockdown in the age of covid-19?

Breaking ranks with the rest of the country, Chennai announced a fresh lockdown this Tuesday for the city and its neighbouring districts. Ironically, Chennai is where the number of dead is the least among major cities. Ahmedabad, Mumbai, Pune and Delhi are all far worse off.

Nearly half of India’s identified novel coronavirus cases sill trace back to just five districts—Mumbai, Delhi, Chennai, Thane and Ahmedabad. But even as things have far from stabilized in these existing hotspots, new geographies of concern are already emerging in tier-II and tier-III cities. The growth rate of new cases is markedly high in districts like Gurugram (5.9%), Nashik and Palghar in Maharashtra (4.7%), and Chengalpattu (3.4%) in Tamil Nadu—even though the overall caseload is not yet high (between 2,000 to 4,000 cases). Could these be the new hotspots?

Delhi and Mumbai hit breaking point by the time active covid-19 cases hit the 20,000 and 40,000 mark, respectively. Now, a wave of infections is set to drown smaller, non-metropolitan cities. What will be their breaking point and when will they reach it?

The lockdown has pushed back the window of peak cases, from mid-June as projected earlier to perhaps mid-October now. But India has merely delayed what’s coming. The curve has not really been flattened, just pushed back.

There are some vital lessons already available based on how the disease has spread within the country so far. Covid-19 has actually been deadlier than the national average mortality numbers suggest. Official data have been frugal and erratic. Modelling efforts have therefore gone awry. But we do know that different regions of the country are going to hit the peak at different times and the following four key learnings could help Indian cities fight the problem better in the latter half of 2020.

The data

Firstly, it is time we counted covid-19-related dead accurately and stopped fudging numbers. A few have been sanguine about the fact that India has recorded just around 12,000 deaths due to the pandemic till now. But a quick look at the rise in the death toll reveals a different story: 87 dead on 11 May, 187 on May 18, and almost 400 deaths each day since 10 June, culminating in a massive increase of 2,004 deaths on Tuesday which was due to misreporting of previous deaths.

The confusion about the count is due to a uniquely Indian problem. Only a fifth of the 10 million deaths a year are recorded. As most people die at home, the cause of death is often uncertain. In times such as these, all deaths are suspect, but because they have been buried or cremated without examination, the cause could very well have been covid-19.

Delhi became an example of this when the discrepancy between hospital records and cremation ground registers came out in the open. In Mumbai, the number of deaths had to be increased by 862, and the numbers are suspect in all cities. It is indeed so important to examine and record the cause of death of every person dying these days. It will enable better tracing and subsequent care and attention. Only Kerala’s cities have done this well till now.

Let us also take a close look at the quality of our numbers. It is an understatement that they lack credibility. The number of tests we have done so far is a far cry from what would have been reasonable. The 6 million tests since February is less than a 10th of what most other countries have done.

We have now seen testing go up significantly and currently more than 100,000 tests are being done daily. But we need at least a million to give us some credible data on where the corona curve is going.

The case fatality rate of 2.8% that some are heaving a sigh of relief about is a facade. If we age-adjust the mortality figures, then Maharashtra’s mortality rate is four times higher than Italy’s, which itself is at 7.2%, among the highest in the world. Essentially, India may have a young population and that may depress the average, but the elderly who end up getting admitted to hospitals deserve to live too.

Our efforts and our preparations are getting undermined by the lack of data. It is frustrating to see how no one can predict, with any degree of robustness, the size of the problem simply because we do not have access to accurate case or death numbers. The Indian Council of Medical Research (ICMR) itself inadvertently advertised this problem when it had to deny a study report that its own people wrote using a model based on official data.

Diversity

We are still unable to explain the huge fluctuations in our disease prevalence. The mortality rate in Kolkata is 9 and in Ahmedabad, 7, while Chennai and Hyderabad are at 1. Mumbai’s mortality rate has remained at 3.5 over the last 30 days but Aurangabad’s doubles at the same time.

The recovery rate in Jaipur is 80%, while in Gurgaon, just three hours away by road, the recovery is at 20%. The reasons that we can speculate on are the varying rates of testing, the deferring proportions of slum populations, the health system capacity and the level of capabilities in municipal governance. But in the absence of regular and reliable numbers, there is no analysis possible.

Health infrastructure

It is beyond comprehension that the public health system in our cities is still not ready to handle the patient load. According to the ministry of health and family welfare, less than 22,000 ventilators are operational. The total number of available beds is a little above 700,000, with only 57,000 ICUs available across the country. If indeed the 40 million infected projection for October 2020 comes true, this paucity of infrastructure could be fatal to huge numbers of poor Indians.

However, that said, one also must realize that there is a larger problem of a lack of healthcare personnel too—doctors, nurses, frontline health workers are all in short supply. Since it seems quite clear that there are probably going to be different peaks in different parts of the country, do we then think of sharing resources across states and hotspots? Is it feasible to have dedicated teams of health personnel moving between cities where their expertise is needed?

Unlocking the economy

The bizarre case of opening up our cities at a time when the infection is booming needs to be discussed. Beyond the obvious trouble spots, Hyderabad, Surat and Kolkata are extremely vulnerable and will be severely under threat in the coming weeks and maybe even months.

By the end of just the first 21-day lockdown period, a Mint plain facts report estimated that 92 million urban workers had run out of their savings and could no longer afford essential commodities. These vulnerable folks have to return to work despite the clear and present danger. It makes little sense, however, to throw them into the fire, with a significant number of them suffering from co-morbidities. Tuberculosis alone kills more than half a million poor urban workers every year.

Solutions

The success in handling the spread in Seoul was simply because of a quick ramp-up in testing facilities. Booths sprang up everywhere and anyone could just walk in to get tested. Kerala contained its urban hotspots by wasting no time in setting up testing centres and getting real-time data.

There is much to learn from the successes in smaller and less wealthy towns like Jodhpur. Mobile teams and quick testing helped identify hotspots and isolate them. Treatment and care followed swiftly. Bikaner did this even better. Acting swiftly, those infected were identified and tested. Contact tracing was quickly established and mobile teams went around collecting data and using it well—both to report the situation and to conduct further tests. It was the coming together of local administration and a state machinery that encouraged the testing and publishing of results. Quarantining was done very strictly and containment zones monitored round the clock, with the government machinery taking charge of delivering essentials.

Dharavi, where nearly a million people live in crowded conditions, is one area everyone was scared about. A dense population living in proximity in a hot and humid city couldn’t afford distancing and quarantining in any manner. The disease started spreading and so did the level of anxiety. However, quick action, huge community involvement, large-scale aggressive testing and a fearless attitude toward sharing real-data seems to have solved a formidable problem.

For cities like Kolkata, Delhi, Ahmedabad and Bengaluru, where at least a third of the population lives in slums, Dharavi in Mumbai is a great case study to emulate. The same applies for emerging new hotspots like Gurgaon and Solapur, where adequate health infrastructure simply does not exist. They need to find innovative solutions that will help them meet the possible surge in infections.

The argument that has been constantly offered is that we must choose between the economy and the pandemic. Between starvation and fever, we are being asked to decide what death is worse. This rather heartless debate speaks volumes about the lack of compassion in our society. Why are we even talking of economic growth when we are looking at 100,000 deaths in our cities in the next three months? The economic cost is indeed serious: 120 million people have lost their jobs and 139 million have potentially run out of their life’s savings. But that does not mean that the state should simply give up now. In fact, the only way out is for the government to take care of this population by feeding them and looking after their health needs. This could at best cost the government an extra ₹3 trillion, less than 2% of the gross domestic product (GDP) and a little more than 10% of the annual budget. Let’s be generous, lockdown our cities for a few weeks more, and feed everyone who is hungry and take care of their healthcare needs.

Amir Ullah Khan is professor of development economics at the MCRHRDI and Saleema Razvi is a senior research economist at the Copenhagen Consensus Center