On the Razor’s Edge

Publication for Observer Research Foundation

As the world reels under the onslaught of the COVID-19 pandemic with the epicentre moving from China to Italy to USA, India stands on the razor’s edge. At one level, India seems far less impacted – approx. 750 active cases on 28 March spread over less than one-fifth (132 districts) out of 720 districts in the country. Given that the first confirmed case was registered on 30 January in Kerala, this spread is far less rapid compared to models in other countries. Yet exponentials have a way of exploding quickly and there is an uncomfortable increase in daily number of infections being registered through March, even after the nationwide lockdown in place since 24-25 March midnight.

The lockdown is unprecedented. China’s lockdown was widely described as “draconian”, possible only in an authoritarian system and yet it covered 760 million people (approx. half the population) at its peak. Democratic India has gone much beyond with its entire 1.3 billion population under lockdown for 21 days. With this, the government has gained a window of opportunity of 21

India’s earlier window was the month of February which India got through with only three cases limited to Kerala, all of whom recovered. But that window was squandered because of lack of coordination within government both at the centre and states, mixed messaging particularly by the ICMR, absence of a national policy and task force which mean that priorities and action points remained ill defined and fuzzy. That is why this 21-day period is the razor’s edge during which India has to do what it failed to do during February.

What was done and how
India issued its first travel advisory on 18 January, asking passengers from China and Hong Kong to self-declare if they had been to Wuhan in the previous fortnight and introduced thermal screening for them at seven Indian airports. Gradually, a few other countries like Japan, South Korea, Singapore etc were added and e-visas stopped in China even as India undertook evacuation flights from early February out of Wuhan.

Universal screening was introduced on 4 March and a week later, all visas for India were suspended. The following week, on 18 March, all international flights were banned. Incidentally, human to human transmission was confirmed by China on 20 January; by 31 January, 50 cases from 14 countries had been reported and on 6 March, the global number of cases had crossed 100000.

Many other countries had tightened entry during this period and taken measures for tracing and testing of possible cases because by end January, it was clear that even infected persons who did not show visible signs of infection could also be transmitting it to others. The virus had been decoded by 24 January by different labs around the world and later baptised as 2019- nCoV. On 31 January, WHO declared the outbreak a Public Health Emergency of International Concern.

Yet ICMR kept emphasising that large scale testing was not needed. As late as 6 March, ICMR notified that “only symptomatic individuals who returned from affected countries (China, Hong Kong, Japan, South Korea, Singapore, Italy, Iran), who had close contacts with confirmed cases and those evacuated from China and the Diamond Princess ship from Japan, should be considered for COVID-19 testing”. The number of accredited test labs was increased from 15 to 57 for real-time Reverse Transcription Polymerase Reaction test (rRT-PCR). Ten days later, 51 private labs were also added but they were asked to procure testing kits themselves and “urged” to do free tests. Expectedly, they remonstrated. It took another couple of days for price fixing. (In US, the initial test cost was pegged by private companies at $3000, reduced to $320 and then made free).

On 21 March, ICMR broadened its guidelines to test all patients with severe acute respiratory illness and even asymptomatic persons with a history of contact. Till then 15701 samples had been tested over the seven weeks. Over 12000 additional samples have been tested during the past week. Meanwhile, 3.4 million test probes are expected from Germany and from WHO. Compare this to South Korea which had 28 cases on 15 February, initiated a crash programme for ramping up production of test kits and was undertaking 20000 tests a day as the production level went up to 100000 kits a day. Germany is currently testing 75000 samples a day. The contrast between these countries and Italy or USA which delayed introduction of large-scale testing reveals a lot.

Even when domestic testing kit producers were asked to come forward, ICMR initially stipulated that the kits would be certified by the US FDA or EU authorities. Only on 26 March was it clarified that Indian agencies (NIV and three other government labs) would do the needful. So far, three domestic kit producers have been cleared. Tests do cost and early testing may not necessarily save lives because most patients recover but testing does help in identifying carriers of infection early thereby controlling onward transmission.

After the evidence of the growing outbreak, Commerce Ministry imposed an export ban on all Personal Protective Equipment. The ban was subsequently relaxed on 8 February to allow exports of most kinds of gloves and masks and a further relaxation for more items provided on 25 February including the raw materials for these products. Belatedly, on 19 March Commerce Ministry reversed its February orders when Indian doctors took to media to complain about shortages of protective gear in hospitals across the country. This was followed up on 24 March with an export ban on sanitisers and ventilators, after the seven Indian ventilator manufacturers had received large export orders from EU nations. WHO had issued an advisory about shortages of such equipment and disruption in supply chains in view of exploding demand as early as 27 February but WHO notices are unlikely to have been referred to Commerce Ministry. Indian authorities are now placing orders with Indian manufacturers and roping in PSUs to double the number of ventilators in public and private hospitals to 80000. US has about 170000 ventilators though only two-thirds can be used due to lack of trained medical personnel. Technological solutions to enable two patients to be connected to one ventilator are also being explored since both patients will be suffering from the same infection.

State governments in Maharashtra and Gujarat advised units to shut down leading to apprehensions among the migrant labour thus sparking a rush for catching trains back home. With 80 districts shut down on Sunday midnight, the rush on trains became a deluge assuming larger humanitarian proportions when the lockdown commenced, shutting down all trains and buses, leaving millions stranded en route. A viable solution for this is yet to found.

Even providing food for 4 lakh poor people as CM Kejriwal announced led to large crowds gathering putting paid to the idea of social distancing. Realising that the rabi crop harvesting season is upon us, the central authorities will need to issue guidelines which are practical and have the flexibility to be adapted to the requirements in different states.

What we need to do and how
These were a few examples of how the window of opportunity in February was squandered. Hopefully, we have learnt appropriate lessons and can make better use of the window that has been provided by the three-week lockdown.

So far, we have seen a top down approach but one that has failed to take into account the competing priorities, diversity across states and adequate consultations with multiple stake holders so that resilience is built into the top down approach to address the unexpected challenges that are bound to come up. For example, even as a list of essential services was notified, so ought to have been details for ‘movement passes’ for providers of essential services by anticipating its need. This could have prevented the scenes of panic buying that were witnessed on the night of 24 March.

Just as greater coordination is needed between different parts of the government structures, there is also greater need to involve the private sector and civil society organisations. The shortcomings in the public health system are too well known to be recounted; suffice to say that dealing with this will require mobilisation across networks with government taking the lead for consultative planning. A national task force with linkages going down to all states and administrative units is vital.

Even as the spread of the disease remains under constant monitoring, we need to prepare for what happens on 14 April when the 21 days get over. The district level mapping will yield pictures of clusters that indicate where partial relaxation of lockdown can be attempted. This will also release resources for where these are most needed. It is an exercise that is delicate but if exercised with care and planning, will send a message of assurance pushing other districts to step up their efforts.

The health system has to be geared up, especially the widespread distribution of testing kits. In addition to the PCR test, there is now an antibody-based test which is cheaper and faster though less accurate. Yet, protocols for where this can be used need to be worked out and relevant professionals sensitised with enough lead time.

Coupled with testing is the need for temporary facilities for quarantine of patients. Ideas of using train carriages and stadiums have been floated but need to be implemented. Medical workers appreciate the recognition of ‘taali’ but also need protective gear. Numbers need to be augmented by bringing in those in medical and nursing colleges who are close to completing their training. Aanganwadi workers and the Accredited Social Health Activists (ASHA) can provide a network of nearly 2 million persons, concentrated in rural and semi-urban areas.

Efforts for ramping up production of HazMat suits, protective equipment, hospital beds, disposables and ventilators is already underway but needs to undertaken on a war footing. The logistics system for movement, storage and distribution of these materials along with the medicines and drugs needs to be tweaked to reduce response times.

Coordinated research to investigate the virus and its attributes that can lead to development of therapeutics has to be focused but not replicated. This needs a network-based approach that ICMR and Deptt of Biotechnology can deliver together.

Society will be called upon to contribute to the safety net that the government has belatedly announced. This will need to be beefed up considerably as the situation evolves and holes become apparent. As it is, the pandemic has imposed a huge economic cost on society. Further aggravation if the safety net fails to alleviate economic stress among the most vulnerable sections of society has social consequences that strain the very fabric of society.

The defence forces are an institution that has both a culture and training for organisational functioning and has been used to mitigate humanitarian tragedies inflicted by natural disasters. Managing the back end of logistics for supply of essential products could be handed over to defence services, particularly in badly affected areas where civilian administrative systems are under strain.

Whatever the debate about the economic costs or about the credibility of the numbers of cases of infection, the lockdown is now a reality. Any debate about it is now passe. The challenge now is to make the most efficient use of the three weeks to ensure that the lockdown delivers, that it visibly demonstrates a government that is transparent, works with a humane touch and a sense of solidarity with the people.

For there is not going to be another window of opportunity.

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