6 min read.Updated: 19 Sep 2020, 07:42 AM ISTRukmini S
Despite early steps, India could not stave off the surge because of later mis-steps and legacy issues in health and administrative capacity
With more than five million cases, India is now emerging as the epicentre of the covid-19 pandemic. India has already overtaken Brazil in terms of total confirmed cases, and at the current trajectory, will surpass the US within four weeks.
Given that the US and Brazil are closest to India in terms of total cases, there can be a temptation to view the three countries and their right-wing leaders as similar, and hence their responses as similar. Yet, India’s Prime Minister, Narendra Modi has been quite unlike US president Donald Trump and Brazil’s president Jair Bolsonaro in his response to the pandemic. While Trump and Bolsonaro have consistently pushed back against social distancing, mask wearing and lockdowns since the pandemic began, Modi was quick to adopt mask-wearing and announced a stringent nation-wide lockdown quite early when India had just over 500 confirmed cases. Yet, India has been unable to tame the pandemic despite the early start. Here are five reasons why.
Lockdowns do not make a country’s cases disappear - unless that country is New Zealand - but they should help flatten the curve of cases, said Giridhar Babu, epidemiologist at the Public Health Foundation of India, and a member of the Indian Council for Medical Research’s (ICMR’s) Task Force on surveillance and research. The government initially claimed that the lockdown was necessary to stop cases. VK Paul who heads the government’s covid task force memorably presented a slide that showed the number of cases in India hitting zero by 16 May at a press conference on 24 April. Later, the government came around to restricting its claim to say that the lockdown lowered cases compared to what they could have been. On Tuesday, the ICMR’s Director General Balram Bhargava reiterated this at a press conference: “We took learnings [from Europe] and we distributed the curve in such a way that we did not have those large numbers of deaths. And that was attributable, scientifically, because of the very effective lockdown that was held in the months of late March, April and May."
States that used the first national lockdown successfully were those that ensured there was no local transmission of cases during the lockdown, and those that prepared their healthcare systems for the coming surge, Babu said.
Researchers have begun to carry out sero-surveillance surveys in some Indian cities to test for the presence of antibodies to the SARS-CoV2 virus that can help determine the true exposure to the virus. In Mumbai, Pune, and in an early national-level sero-survey, the data shows that antibody prevalence is far higher in slums than in non-slums.
Household contact was the most common way of spreading the virus, an analysis of data on the source of transmission from Tamil Nadu and Andhra Pradesh  showed. The lack of a personal toilet in particular is a strong predictor of sero-positivity. “Higher prevalence in slums could be due to population density and shared common facilities like toilets, water points etc," said Ullas Kolthur, one of the principal investigators of the Mumbai sero-survey and a scientist at the Tata Institute for Fundamental Research.
3) Administrative incapacity
There is growing evidence that many states did not prepare their healthcare facilities for the looming pandemic during the lockdown, some because they simply could not.
“Tamil Nadu and Karnataka put in central oxygen lines in government hospitals, which did not have them until then, which was a vital step to take, and could partly explain their low mortality," said Babu. In contrast, several cities in Maharashtra are currently experiencing acute shortages of oxygen, as are other cities that are currently facing a surge in cases.
Along with medical infrastructure, there is also a manpower crunch, as well as the challenge of managing supplies including ventilators, oximeters, and drugs, said Babu.
Additionally, India has struggled with non-medical tools of pandemic control. Contact tracing is supposed to be a key pillar of the government’s containment strategy, but even cities with better administrative capacity have struggled with contact tracing when the surge hit. News reports from Mumbai reported in late May that the city’s contact tracing staff was overwhelmed and the exercise was falling behind.
Bengaluru made tech-led contact tracing a key part of its lockdown preparedness, Munish Moudgil, the IAS officer in charge of Karnataka’s covid war-room, said in an interview. Indeed, the city was tracing a large number of contacts per confirmed case in May, and Karnataka had the highest contact tracing of any state, according to ICMR data. However, when the surge hit the state in late June, primarily via Bengaluru, contact tracing faltered in the IT powerhouse as well.
When the ICMR released a study based on its testing data in late May, a majority of those tested did not have data about their symptoms, travel or contact history completed. Even now, this data is lacking. “Every evening, we receive from the ICMR a list of people in the state who tested positive," a senior advisor to the Delhi government said, requesting anonymity. “Some have names but no phone numbers, others have no addresses; in some cases even the name is just a first name. Vinay, full stop," he said in exasperation.
4) Testing troubles
For the first few months of the pandemic, the criticism about India was that it was testing too little, and India is still only 115th out of 193 countries in terms of tests per million population. The test positivity ratio (TPR) - the number of tests conducted that come out positive - is an indicator of whether a region is testing enough as compared to the size of its outbreak. High-burden states such as Maharashtra have an outsized TPR that has only grown over time.
Then, there is the question of which tests a state is using. Since an ICMR advisory in June asking states to ramp up testing using rapid antigen test kits, many states are now conducting more rapid antigen tests each day than RT-PCR tests. Antigen tests are quicker, cheaper and easier to conduct. But they are also much less sensitive than the gold standard RT-PCR test, meaning that they are much less likely to pick up positive cases. To combat this, the ICMR guidelines say that every symptomatic person who tests negative on an antigen test must be retested on an RT-PCR test. But in many states, the administrative capacity to follow-up with these symptomatic negatives simply does not exist. A large number of such people have been missed, health secretary Rajesh Bhushan said at a press conference last week, and could be responsible for spreading the virus. Even in Delhi, fewer than 1% of 7 lakh people who took antigen tests were retested, the Indian Express reported.
5) Limited state relief
Some medical authorities have begun to blame the spread of cases on “indiscipline", especially as cities begin to “unlock". But given the impact that the pandemic and lockdown have had on the lives of the country’s poor, shifting the burden to individual responsibility may be unfair. Close to 120 million people lost their jobs in April 2020, according to data from the Centre for Monitoring the Indian Economy, although a portion of these jobs might have returned. There was a nearly 40% year-on-year increase in the number of people seeking work under the Mahatma Gandhi National Rural Employment Guarantee Scheme between April and September, the government said in Parliament on Monday. State support has been limited in the country. In contrast, Brazil under Bolsonaro has extended its welfare schemes, and added emergency support, raising the incomes of the country’s poorest 40%.
Modi may have taken the virus seriously, but there was much else that India did not or could not do to stop it.