Publication for Observer Research Foundation
India had a generous lead time in preparing for the COVID-19 outbreak but it is running out, fast. The first case in India was recorded on 30 January, in Thrissur, of an Indian student who had returned from Wuhan. Two other Wuhan returned students also tested positive in Kerala in the next four days. All three have since recovered.
At this time, there were approx. 10000 cases recorded in China, concentrated in Wuhan, and another 98 in 18 other countries. Wuhan city with a population of 11 million and Hubei province with a population of 60 million had been sealed off from the rest of the country on 23 January though by then nearly 5 million people had travelled out, for the Chinese New Year holidays, beginning that weekend, including the three Indian students. On 31 January, WHO declared 2019-nCoV a “Public Health Emergency of International Concern” and on 11 February, the disease was baptised by the International Committee on Taxonomy of Viruses as COVID-19.
The month of February was India’s lead time as no further cases were recorded even as 5000 cases were recorded in over 60 countries including new clusters emerging in South Korea, Italy and Iran. By end February, China had exceeded 77000 cases with over 2700 deaths. In early March, came the report of one case in Hyderabad (travel history to UAE), one in Delhi (travel from Italy) and an Italian in Jaipur. Numbers went up when all 14 Italians in the group tested positive. By the end of the first week, the number had crossed 30 and then 100 by mid-March. The following week has seen a further jump to over 250 cases.
By this time China had succeeded in bringing the spread under control with cases having crossed 80000 and casualties at 3245. However, infections in other countries had zoomed to over 160000 now spread over 148 countries. Italy was badly hit with 47000 cases and over 4000 dead, followed by Spain, France and Germany. Cases in US crossed 17000 after the first having been reported on 21 January. On 11 March, WHO declared the outbreak a global pandemic.
PM addresses the nation
India’s lead time is clearly running out. Prime Minister Modi addressed the nation on 19 March highlighting the enormity of the crisis facing the nation. His speech was motivational, urging people to adopt social distancing, refrain from panic buying, displaying generosity towards weaker and economically vulnerable sections and observing a self-imposed curfew on Sunday 22 March. It however fell short in identifying and putting forward measures taken by the government to deal with the challenge.
During March, government progressively curtailed entry into India from other countries, finally prohibiting all international flights from 22 March till the end of the month. Most states have banned public gatherings, closed down schools and colleges, shopping malls, clubs, cinemas and restaurants though in some cases, restaurants with limited seating can function. Public transport systems are shut down for Sunday, but this cannot be continued if essential services like health, banking, power, communications etc have to be maintained.
Dr Balram Bhargava, head of Indian Council of Medical Research declared on 13 March that India had had 30 days to prevent community transmission, the third stage in transmission which catapults the outbreak into an epidemic. The first two stages related to the import of the virus followed by the local spread through direct contact with those infected. The confirmatory test for the virus is rRT-PCR (real-time reverse-transcription polychromase chain reaction). It is a two-stage test, first to confirm that the virus belongs to the Coronavirus family and the second to identify it as 2019-nCoV. ICMR had identified about 60 government labs and was in the process of building up stocks of testing kits from a lakh to a million. Accordingly, ICMR was in favour of testing only those
with symptoms (fever, cough and respiratory distress) who had either a travel history or had been in contact with an infected person.
The head of WHO Dr Tedros Adhanom Ghebreyesus urged countries “to test, test, test; test every suspected case”. Reacting to this Dr Bhargava said on 17 March that this doesn’t apply to India. At the same time, clearance has now been given for 51 private labs to also undertake PCR testing. However, ICMR has neither assured them of adequate testing kits nor provided costing guidelines. During the H1N1 outbreak in 2009, private labs were brought in and the rate fixed at Rs 4500. ICMR is importing two large units that permit rapid testing of 1400 samples daily but this will take another two weeks. The low numbers are used as evidence by ICMR that community transmission has not taken place though the critics allege that you can’t find evidence if you don’t look for it.
Many other countries have resorted to large scale testing. China resorted to it in early February, testing 10000 samples a day. South Korea had 28 cases on 15 February and adoption of early large-scale testing of 20000 samples daily enabled it to limit the cases to 8600 whereas Italy which had 3 cases on 15 February ended up with 47000 cases having adopted large scale testing three weeks later.
On 18 March, Roche Diagnostics was approved by ICMR to undertake testing. Other applications for approval of diagnostic kits by Indian private companies are still pending. Given that the genome sequence had been put out in the public domain on 24 January and the National Institute of Virology in Pune independently isolated a pure strain of the virus, early development and approval of diagnostic kits would have helped generate a greater sense of assurance. Larger volumes would help in bringing down the cost of the test, currently estimated at Rs 5000. Mechanisms to provide the kits to the approved private sector labs would enable them to offer tests freely and on widespread basis. Separately, ICMR is still working on a Rapid Response Regulatory Framework.
From the information now being pieced together, it seems clear that the disease surfaced in China in late November/early December in Wuhan. It was initially diagnosed as a new disease with pneumonia like symptoms resistant to known anti-flu drugs. Dr Li Wenliang who chatted about a “new SARS like virus” in a WeChat group on 30 December was severely chastised by the local authorities. He later contracted the infection and died on 7 February.
WHO was informed about the new illness on 31 January but continued to parrot the Chinese view that there was no evidence of human-to-human transmission till 21 January even as the Wuhan authorities held the biggest dinner party for the Lunar New Year for 40000 families on 18 January. By the time Beijing locked down Wuhan on 23 January, cases had been reported in South Korea, Japan, Hong Kong, Taiwan, Thailand, Singapore and US.
After the crackdown, the narrative changed from China’s initial negligence to how China bought time for the rest of the world with its draconian quarantine amid stories of how quickly temporary hospitals were being put up and 30000 medical personnel moved to Wuhan; in short how well the system had responded. China may now be offering assistance to other countries like Italy and Iran but there is no denying that its negligence over weeks has severely damaged the image of a responsible global stakeholder that President Xi Jinping was eager to cement.
The global health challenge is being closely shadowed by an economic challenge in many countries. For a country like India with a large unorganised labour sector this makes the challenge greater. Right now there are trainloads of migrant labour from Gujarat and Maharashtra who have been laid off heading back to their villages. Only Kerala government has come out with a plan to provide resources for the economically vulnerable who run the risk of losing their livelihood. a national strategy would provide guidance to the states as also the assurance of resources.
With seven beds per 10000 of the population compared to 29 in US and 34 in Italy, India has a weak public health system. To deal with such a challenge needs not just all of government but government, private sector and civil society to work together. What is needed is a national task force and clear targets regarding testing kits, hospital beds, and lead funding the biotech industry to work collectively for a vaccine and not inconsistent messaging. Exhorting the people to exercise Sainyam (restraint) and Sankalp (determination) is certainly the task of a political leader but it will carry greater conviction if there is also evidence of sharp focus and coordination. Government cannot afford to waste the valuable lead time that India gained for it is fast ending.