The number of Covid-19 cases in India has surged rapidly since June, making it the third-highest country in the world after the US and Brazil in terms of case tally. India also had one of the harshest lockdowns in the world, which is thought to have pushed millions into poverty, though Prime Minister Narendra Modi and his ministers have maintained that this helped the country tackle the pandemic.
However, the situation is still alarming, with even states and cities which were initially successful in containing the spread seeing a re-emergence in recent days (see here and here).
A countrywide lockdown was not only unnecessary, but also too costly for the poor, Imrana Qadeer, distinguished professor at the New Delhi-based Council for Social Development and a public health expert, told HuffPost India in an email interview.
“Lockdowns in high infection zones at an early stage can slow down the pace of infection, but for successful containment of the disease we need to utilise that time to expand monitoring and medical care facilities and in the meantime offer basic security to the poor,” said Qadeer, who taught at Jawaharlal Nehru University for 35 years.
A national lockdown without these measures, she said, only delayed the spread without containing the disease.
She also explained the dangers of relying on herd immunity in India, a theory that has sometimes been proposed, especially on social media. “Leaving populations to develop herd immunity would mean non-action and letting the virus spread fast when we know that some severe and critical cases are fatal, particularly if they don’t get medical care.”
It would also overwhelm the hospitals and the young people will take the infection back to the vulnerable elderly.
Qadeer, who wrote a paper on India’s testing strategy in Economic & Political Weekly along with Sourindra Mohan Ghosh, also said that the Arvind Kejriwal-led government in Delhi could be faulted on two counts for its botched response: starting diagnostic testing (rt-PCR) very slowly and its failure to utilise the lockdown time to improve medical care facilities.
Delhi now has the third highest case tally after Maharashtra and Tamil Nadu in the country, and the Kejriwal government has been severely criticised, though the situation seems to be improving slightly now. Amid complaints of unavailability of beds and concerns over a dip in testing numbers last month, the disagreement between the AAP government and the Lieutenant Governor made matters worse.
The political competition between the centre and Delhi government was also to blame for the situation in Delhi, said Qadeer.
1. Delhi began its Covid-19 strategy promisingly, with Arvind Kejriwal’s announcement of a 5T strategy. Where do you think the government faltered?
Despite its 5T strategy, technically Kejriwal’s government can be faulted on two counts. The first is that it started diagnostic testing (rt-PCR) very slowly. On 1 April, Delhi government tested less than 2,500 samples conclusively (i.e. laboratory confirmed positive or negative results) whereas its neighbouring state Rajasthan, for example, tested almost 6,800 samples with conclusive results. On 15 April, Delhi tested 15,443 samples compared to Rajasthan’s almost 33,000. This was despite Delhi having 50% more laboratory confirmed positive cases than Rajasthan by then. This means case tracking in Delhi was low. It prevented early detection, treatment and containment strategies when one could isolate/quarantine infected individuals (even at home) to prevent spread of infection.
The second is its failure to utilise the time of the lockdown — when spread of the disease was relatively slow — for expanding monitoring and medical care facilities. Adequate numbers of quarantine centres and makeshift hospitals for severe or critical patients should have been built early which they are doing only now. They lost valuable time.
These flaws however have several additional underlying reasons that undermine Kejriwal government’s resolve:
- Delhi was the second city to get affected. The health ministry, Delhi government and the MCD were ill prepared to handle the pandemic given that neither did they have Kerala’s experience of handling epidemics successfully nor did they draw any plans against the possibility of the pandemic reaching Delhi or informed citizens, even though international travel and information flow was there. This led to hurriedly drawn inadequate advisories by the ministry and the ICMR, such as testing being limited to only breathless patients, which meant missing early cases.
- The violence against anti-CAA protestors and the anti-Muslim riots had created social and communal tensions. In the absence of aggressive efforts to establish peace, rebuild trust and heal wounds, community participation in at least four of the five components of the Ts was difficult and not even attempted.
- The massive movement of the working population towards villages, the crowding at transport sites and their stoppage and eventual camping at the three interstate borders of Delhi — due to the lockdown — created more stress on the administration as the threat of spread increased. The population that remained but without any resource or livelihood had to be fed. The state was short of resources to feed them, but was still forced to purchase grains from the Centre which put further strain on state resources.
- Multiplicity of control over its healthcare facilities where the state government controls only two major hospitals LNJP and GTB (and Deen Dayal Upadhyay Hospital), all others are under the Centre or MCD. Coordination, cooperation and fair financial distribution became difficult due to political competition. As a result, no open systems were developed to inform the public about bed vacancies and service availability in the city, despite talks about modern communication systems and use of dashboards. This was at the cost of patients who had to run all over and lose critical time. The political conflict is reflected in the fact that the Centre first allowed Delhi to go down and then stepped in to add beds, cap private hospital charges, increase testing facilities and took credit for it. The AAP Government was hiding information on deaths and quietly purchased grains for distribution from the Centre to retain its image of being in control of the crisis instead of exposing the lack of support and cooperation of the Centre. This was an obvious mistake and a political miscalculation as Kejriwal lost the goodwill and trust.
- Even by mid-June, only 8,000 beds were declared as Covid beds for the 19 million population. The shortage of personnel and materials, especially PPEs, for health workers was also detrimental. Neglect of hospitals victimised their staff and added to the problem. This ill-management of resources of the national capital was not openly addressed. AAP instead chose to be led by its political opponent.
- The AAP government failed to invigorate its mohalla clinics and ward committees to educate, inform and mobilise people to overcome their fears and mistrust and come forward to help. It did not link ASHAs to these institutions to help the Covid-19 control campaign among marginalised communities nor did it integrate its food provisioning to the jobless with this educational and preparatory activity with the help of ward representatives.
Handing over public health work entirely to police was a mistake and it was disillusioning. Its strategy to provide free medicines, surgery and clinical care was welcome but the lack of attention to long-term strategies of providing water, sanitation in resettlement colonies and slums made hygienic practices impossible. In short, failing to build on trust and popularity, neglecting a public health approach that could have helped cope with the problem with limited medical care facilities was a fault. Hiding facts and not confronting discriminatory attitude of the Centre to demand help as a right is where the AAP government faltered.
(Ed — The Union Home Ministry said this week that over 20,000 tests are being conducted in Delhi daily and the recovery rate in the national capital is over 72%.)
“The chaos and confusion is because of the lack of such a coherent strategy guided by scientific public health principles”
2. The Delhi government had urged asymptomatic people to refrain from getting tested to avoid a system collapse (LG later asked Delhi to follow the ICMR guidelines). Do you think this was an effective strategy? ICMR’s guidelines also say only asymptomatic direct and high-risk contacts of confirmed cases should be tested. Is it enough to just test direct contacts?
The system collapsed in Delhi in the first place because the infected people were not diagnosed, monitored and treated and the infection was allowed to spread. Kerala, for example, diligently traced and tested contacts of infected individuals from day 1 and has so far managed to minimise the spread within the community. There is still no definitive proof that even true asymptomatic people (i.e. those who never develop any symptom) or infected people during asymptomatic phase do not spread the disease. Many people who appear asymptomatic now develop symptoms later. Some become severe or even critical. Lack of testing prevents early diagnosis and treatment. A rider is that testing must be accompanied by a massive educational campaign of home quarantine, isolation and scientific knowledge about the disease. The ICMR itself faulted on criteria for testing, if anything, it should have included testing of indirect contacts as well. For the Delhi government to restrict it further was not correct.
(Ed—Kerala has witnessed a surge in cases recently, especially those infected through local contacts, according to reports. The state recorded 301 fresh covid-19 patients on 8 July and nearly one-third of them were infected through local contacts, Livemint said, pointing to the virus spreading in the community undetected.)
3. We have seen policy uncertainty around the Covid crisis, with both the Delhi government and Union government issuing and then withdrawing controversial orders. Has this contributed to the panic and chaos in hospitals?
Policies evolve with experience and clarity of objectives. When public health objectives get mixed up with political priorities and decisions are not transparent, as the contradictions in directives show, there is bound to be confusion at the institutional level and in the implementation. What Delhi required — and still requires — is a coherent strategy formulated by a team of public health experts, epidemiologists, virologists and social scientists with adequate public representation, close monitoring of the situation and an effective implementation of that strategy by the state and the central government in collaboration with each other. The chaos and confusion is because of the lack of such a coherent strategy guided by scientific public health principles. This situation does not reflect well on either of the governments.
4. In Delhi, both Covid patients as well as those suffering from other diseases are struggling to access medical facilities now. How can the government fix this?
That’s something which is happening not just in Delhi but most of the states, and in many countries — except the ones that contained the pandemic at an early stage. Unfortunately, our meagre healthcare facilities cannot cover and treat all patients suffering from other diseases as well as Covid patients. The claim of adequate beds hides the fact that the cost of private hospitals discourages the majority that is in the public hospital waiting list. Both the governments failed to be firm in regulating private labs in providing free testing and curtailing prices that make them inaccessible to many despite capping. Despite six months, there is no serious review of budgets and increase in investments to strengthen the public sector, sanitation and water supply in poorly serviced areas. Even the expert committee keeps pushing for private collaboration. Unless this is done on a long-term basis there will be no solution. Turning public hospitals into Covid centres pushes non-Covid cases into the private sector and the majority then drops out. Without infrastructural strengthening, including building makeshift facilities, mere personal hygiene methods may slow the epidemic but won’t solve the problem of displaced routine patient care and even emergencies as shown by several reported cases.
5. In an EPW article you co-authored, you wrote that contact tracing and quarantining those found infected can break the transmission chain. Apart from Kerala, it seems like other states have given up the attempt to trace contacts. How big a setback has this dealt?
That is the main component of containment strategy. Failing that made containment impossible.
6. You also wrote in EPW that the daily case number only makes sense when read along with the corresponding testing rate and that barriers to testing must be removed. Have the states that were lagging behind made any progress in this?
Diagnostic testing is important for early treatment as well as to identify infected individuals to break the chain of transmission of the disease from one person to another. In an ideal world, we would have liked to test every suspected individual and their direct/indirect contacts with sentinel surveys to assess disease status in the community at one go, identify the infected and isolate them. But that’s not possible. We don’t have resources or personnel. So we strategise testing by tracking contacts of all lab-tested confirmed cases. The more confirmed cases are identified, the more should be our testing. The problem is if the pandemic is not contained at an early stage, testing simply can’t keep pace with the rising number of confirmed cases. So the initial response is very crucial. The states that lagged behind in the initial stage and missed the chance, find it difficult to catch up now despite efforts. The focus here has to be protecting the vulnerable population and strengthening medical care services by adding to public infrastructure and rigorous regulation of private sector along with containment and continued testing. Public awareness, practicing hygiene methods and physical distancing, allaying fear and promoting public participation by different means — voluntary testing, creating community-based quarantine spaces, linking up with local clinic for supervision of those in home isolation — and promoting rational approach to disease is a component that is consistently ignored by the official experts and the state.
A serious problem is data obfuscation which has increased over time. Point of care rapid antigen testing was introduced in India sometime back to boost testing. But it has created problems about interpretation of testing data. Antigen testing is known to have low specificity (i.e. positives are wrongly diagnosed as negatives) compared to the rt-PCR tests. The current ICMR guideline is to again conduct confirmatory rt-PCR tests on people showing negative in antigen tests. So the same people are tested twice. By the number of samples tested, we can’t know how many people are tested if that data is not clearly reported. There is an additional problem. Some states are clearly reporting data of total samples collected and out of that the positives and negatives; the rest are the samples where results are pending (and a few samples with inconclusive results). But some states (including some that were earlier reporting this, like Delhi) are not using the same format anymore, thus obfuscating data. So we don’t know from their testing numbers how many are conclusive rt-PCR tests (diagnosed in a laboratory as positive or negative) and how many are just collected swabs from individuals not yet tested in a lab. All states right now need to give out the number of people conclusively tested as positives and negatives on a daily basis, separately for rt-PCR and antigen tests.
7. You’ve written that the only viable exit strategy from a complete lockdown is investing in the primary healthcare system, and building trust among the poor, who were disproportionately hit by the restrictions. Is the central government making any attempts to do this?
For that it needs to increase expenditures substantially on health and social security relief measures. The extension of Garib Kalyan Yojana till November is a welcome step but more needs to be done. The amount of pulses and cereals should be doubled, cooking oil should be included in the provision too. Updating the NFSA (National Food Security Act) beneficiary list is urgently needed.
According to some estimates, the central government so far has allocated roughly 1.1% of the GDP in fiscal expenditures for various additional relief measures, which is grossly insufficient given the context. The important challenge is to build long-term permanent institutions such as an expanded and strengthened PDS system and NREGA, which are permanent right based programmes and not short-term doles with a patronising and charity connotation.
8. Is India moving towards herd immunity? A Princeton study said herd immunity can work in India because of its young population and 60% of the population can be immune by November if the virus is unleashed in a controlled manner. What are the dangers associated with herd immunity in India?
We need to understand that herd immunity, unlike vaccine-produced immunity, is a natural process acquired even in the absence of vaccination. Hence, though it is influenced by human interventions to prevent disease, it is indirect and not induced by it. When a large percentage of the population acquires an infection, depending upon the nature of the pathogen it may or may not develop immunity. The immunity may be permanent or temporary. It is estimated that in the case of Covid, 60-80% of the population has to be infected when those not infected can be shielded by the acquired immunity of the infected around them. Surrounded by immune persons, a non-immune person is indirectly protected as the pathogen cannot reach them through this human shield. Vaccines evolved to cut short the dependence on this not so predictable though natural process. It exists irrespective of policy.
In the case of smallpox too, it was assumed that herd immunity will work with 60-80% population coverage with vaccine, but it did not work with this kind of coverage. WHO chose to use the strategy of identification and immunisation of the family and the surrounding population of the village. While smallpox was a virus that spread very slowly, Covid has a much higher reproducibility rate and hence, whether even this proportion of population coverage works is not definite. Leaving populations to develop herd immunity (‘herd immunity approach’) amounts to non-action and letting the virus spread fast when we know that some severe and critical cases are fatal, particularly if they don’t get medical care. Letting infection spread quickly will overwhelm hospitals with a rush of patients. Also, we can’t protect our old and expose the young – which the proponents propose; not in a country where population density is high, small rooms and basic amenities are shared by many. In India particularly, those infected young people will take the infection back to the vulnerable elderly.
9. As the case count increases, health workers are overburdened and not getting enough rest. What are the dangers associated with this?
We have seen reports of nurses falling down in the wards due to exhaustion and health workers in the field complaining of long hours of work and yet not being able to complete duties. Exhaustion, especially in critical care, can affect the efficiency of the team and at times may lead to inappropriate decisions. It may also make the exhausted person more vulnerable to mistakes and increase their vulnerability and those of others.
10. The national lockdown extracted a heavy cost, particularly from the poor. Was the economic and social misery justified?
A heavy cost for what benefit? A lockdown of regions where there are no (or very low) infected cases is not required. Rather they require monitoring, testing and treatments. A countrywide lockdown was not only unnecessary but in itself very costly for the poor, with benefits only for the elite who perhaps felt taken care of. The benefit of a delayed spread was neutralised by the economic disaster for the poor and their exodus from the city in which they suffered hunger, humiliation, pain and death and watched their children suffer. Can this ever be measured in monetary terms or justified? As I said before, closing down the borders of high infection zones at an early stage insulates the uninfected/less-infected areas. Lockdowns in these areas at an early stage can slow down the pace of infection (compared to a no lockdown situation), but for successful containment of the disease we need to utilise that time to expand monitoring and medical care facilities and in the meantime offer basic security to the poor. A national lockdown without these measures only delayed spread without containing or rooting out the disease while paying a steep economic cost — especially for the poor.