Publication for Observer Research Foundation

As the 21-day lockdown announced on 24 March neared the end on 14 April, Prime Minister Modi delivered his much awaited address. Expectedly, he extended the lockdown by another 19 days till 3 May. Limited relief in districts where the disease is in check may be allowed after a week. Guidelines regarding these are yet to be issued.

The extension of the lockdown was inevitable. Even after 21 days, the spread of COVID-19 has continued, both horizontally and vertically. From 128 districts out of 729 that had confirmed cases on 24 March, the horizontal spread now covers 375 districts. The pace has continued to reflect a doubling rate of four days since 14 March when India crossed the 100 cases threshold. The last doubling from 3200 cases on 5 April to 6400 cases took five days and at these rates, the number of cases would exceed a lakh by the end of the lockdown. The major lacuna has been testing which has picked up only during the last ten days to about 18000 tests a day. However, the number of tests so far (2.3 lakh against the over 10000 positive cases) are about a fifth of what was needed to provide a better picture of both the vertical growth and its likely direction.

A Change in Modi’s Approach
This time there were two key differences compared to Modi’s address three weeks ago announcing the lockdown. First, it was preceded by widespread consultation with the chief ministers. This reflected an acceptance of India’s federal character and the fact that the district is the fundamental unit of administration. Any scheme or plan, in order to be implemented effectively on the ground across the country, needs a two-way up-down information flow through certain well established channels.

The second difference was the shift from the “jaan hai jahaan hai” sentiment to the “jaan bhi aur jahan bhi” objective, announced after the meeting with the state chief ministers on 11 April. Once again, it reflected an acceptance that while a national lockdown had been a top down decision announced without wide consultations and with a mere four-hour notice, it was not the solution and a staggered relaxation of the lockdown needed to be managed by each state government looking at the situation in each district. In coming days, the new guidelines will begin to delegate the responsibility of staggered relaxation to the state governments. Modi realised that even extending the lockdown was also better done following consultations.

The “jaan hai, jahaan hai” sentiment gave rise to a binary approach. Those supporting a lockdown became labelled as supporters of health security while those who asserted that a lockdown would only kill the poor person saved from coronavirus though starvation caused by economic hardship were believers in economic security.

The binary choice is a false one as it blunts critical thinking. It was convenient for the central government because instead of adopting an analytical data driven approach, it was simpler to motivate the people by evoking the image that India was fighting a “war” and victory demanded an unquestioning rallying around by the population. It fitted well with Modi’s governance style. The downside of it was that it also activated the panic virus which spread far from rapidly than the Coronavirus resulting in the unforeseen challenges (keeping essential services running, reverse migration, economic hardship of the vulnerable sections etc) and fumbling policy responses.

The reality is that India had been slow in developing its responses. India’s lead time was the month of February during which India had only three cases limited to Kerala, all of whom recovered. But that opportunity 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. The 21-day lockdown was intended to extend the lead time for ramping up medical preparedness because Modi knew full well that the abysmal state of the health infrastructure in India would be overwhelmed very quickly unless there was a war like approach to enforce suppression.

On 14 April, it became clear that suppression had yet to show a conclusive downturn. More time was needed to build the health infrastructure as well as the database so the planners could get ahead of the curve. And so, the lockdown needed to be extended.

Changing the Governance Model
Before the national curve can be flattened, each state has to flatten its curve and the credit for it will accrue to state governments that demonstrate effective governance, use technology tools, employ grass roots outreach and have better information flows with a motivated administrative machinery. The centre’s role will be providing the fiscal space and at best, access to scarce equipment like PPEs and masks. Modi now understands (perhaps reluctantly) that if there is credit for successfully curbing COVID-19, it will have to be shared with state chief ministers whether from BJP or other parties. Note that now the models for tracking and controlling spread being talked of are the Bhilwara (Rajasthan) model, the Pathanamthitta (Kerala) model and the Agra (UP) model; it is no longer the one size fits all model designed in Delhi.

This is equally true for managing the lockdown exit. The economic machine of the state was brought to a shuddering halt on the midnight of 24-25 March. The resulting demand shock and the supply squeeze sparked a series of fall-outs including highlighting the risks of a crisis in some sections of the financial sector where money circulation has slowed down exposing unsustainable debts burdens. The support needed for the informal sector of the economy in terms of welfare, food and direct benefit transfers is very different from the stimulus and tax breaks needed for the organised sector. It is clear that the economic engine cannot be kickstarted as simply as its was switched off. And therefore, managing the exit out of the economic lockdown has to be gradual and fine-tuned but will require a high level of coordination between the centre and the states, with the latter taking up a major share of the management.

The fight against COVID-19 has just begun. It will continue over time. It is possible that in some areas, gradual relaxation might lead to a spike in infections leading to a reimposition of restrictions. This process could take months or even a year till effective vaccines and therapeutics are available. Even then, the story doesn’t end.

Viruses have a tendency to mutate and sometimes become endemic in some societies. We have seen this with the H1N1 which continues to afflict India after the initial outbreak nearly a decade ago. Casualty figures have averaged over a thousand a year and some years have been difficult, the worst year being 2015 when India had more than 42000 infectious cases and nearly 3000 people died. Just last January, six Supreme Court judges tested positive for H1N1.

Even as India weathers the current crisis, the long term challenge for the government will be to build a pandemic resistant infrastructure so that artificial binaries between health security and economic security are avoided and we are better prepared in future.

Publication for Observer Research Foundation

India is halfway through the 21-day lockdown announced by Prime Minister Modi on 24 March to tackle the growing challenge of COVID-19. At the outset, it was clear that the lockdown was not a cure. It was a drastic measure to break the transmission chain and also gain an additional valuable 21 days to prepare a plan and put in place systems to implement it effectively after the lockdown was lifted.

India had an invaluable lead time in February when only three cases were registered in Kerala between 30 Jan and 3 Feb, all students returning from Wuhan. The next round of cases began in March which included patients with history of travel from other parts of the world. During this period, the numbers in China went up from 10000 to 78000 and the disease spread to 60 countries with new clusters emerging in South Korea, Italy and Iran. Yet, other than putting into place screening measures for people coming from certain countries, little was done to prepare for the impending outbreak. Universal screening was introduced on 4 March; all visas for India were suspended after a week, followed by a ban on all international flights on 18 March.

During February, no plans for procuring or producing test kits were prepared because internal debates about testing criteria continued. Even as the global numbers crossed 100000 on 6 March (it crossed a million 26 days later), India struggled with plans for adequate safety equipment like masks, gloves and protective suits for the health service workers as well as estimates for essential equipment like respirators, ventilators and adequate beds in isolation wards.

Meanwhile, the virus continued to spread. After reaching a hundred cases on 16 March, it began to double every four days. After a trial run with a “Janata Curfew” on 22 March, the 21-day lockdown began on 25 March. PM Modi has since spoken twice, once during his Mann ki Baat radio address on 29 March when he “apologised” to the people for the hardships caused by the lockdown and again on 3 April when he exhorted people to light a candle or diya for nine minutes on 5 April at 9 PM after switching off lights, in an act of solidarity. In all likelihood, he will speak again on 14 April to inform the nation of the next decision, whether to continue, partially relax or lift the lockdown. On what will this decision be based?

We know that the initial decision was intended to break the chain of transmission. So has that happened? The current assessment is that COVID-19 has a Basic Reproductive Number (Ro) of 2.9; this is the number of people that each patient is likely to infect further. Breaking the transmission chain means bringing this number to below 1, implying cutting it by two-thirds or more. A conclusive determination can only be made on the basis of data. As on 3 April, according to ICMR, only 70000 tests had been conducted across the country. The officially declared increase in the number of cases continues its four-day doubling cycle. On the basis of this limited data, the transmission chain is yet to be broken. In coming days, the data set needs to be expanded significantly; testing needs to grow to a hundred times the number of cases to enable arriving at a definitive conclusion.

However, ICMR continues its flip-flop on tests. In addition to the more accurate real-time Reverse Transcription Polymerase Reaction test (rRT-PCR), a faster and simpler (though less reliable) serum test to detect antibodies is now gaining widespread acceptance. A positive result with this needs to be further verified by using the PCR test. However, ICMR is undecided and a protocol regarding the antibody test, about where this should be employed is still awaited.

On 24 March, PM Modi had announced a Rs 15000 crore package for rapid strengthening of the healthcare sector. The resources were intended to step up procurement of protective equipment, ventilators, build quarantine centres and train medical workers. Large orders have been placed for these but deliveries have yet to pick up. Ramping up domestic production is difficult during a lockdown because of supply chains of inputs – fabric, special coated synthetics, zips, pressure valves etc, down the chain and employment of labour at each stage; global supplies have become scarce.

It is correct to claim that the pandemic has to be fought on a war footing; however, without data and without protective equipment, it is like fighting a war blindfolded and without weapons.

Every war has its share of the unexpected. However, the impact of the lockdown on the economic chain, even if expected certainly did not anticipate the extent of the reverse migration of the migrant labour. It has thrown up new challenges of ensuring food security and adequate welfare measures. Partial reversals could ease the economic pain but would adversely affect the objective of breaking the transmission chain. Yet it is important to remember that economic pain can be reversed but death cannot be, whether due to disease or other aggravations.

It is likely that government may therefore consider a partial relaxation. Such a suggestion was implicit in the video conference that PM Modi undertook with the CMs of the states on 2 April. Yet a common exit strategy cannot be uniformly applied across all states because the spread of the disease is not uniform. From 18% districts (132 out of 729) affected when the lockdown was announced, the disease has now spread to 33% districts (238). Certain regions are more highly impacted even as there are areas that are clear. These would be likely candidates for relaxation of lockdown after 14 April so that economic activity can recommence even as careful monitoring and testing ensures that these districts remain green zones. It will also help in staggered harvesting.

Technology needs to be used extensively. Mobile phones enable location tracking, extensively employed in other countries for contact tracing provided it is accompanied by widespread testing. Road movement cross-verified with petrol/diesel offtake and mapped with disease helps anticipate and correlate spread with movement. Districts remain the fundamental administrative unit and it is here that the battle has to be fought and won.

Planning has to be done on the basis of tracking the disease using data to develop epidemiological models that can predict the movement of disease. Strategy implementation has to be done at the district level for which resource allocation and sharing becomes the state and central responsibility.

The lead time gained with the 21-day lockdown will come to an end in another ten days. It will not see the end of COVID-19 and more sacrifices by the people will still be called for. But hopefully, on 14 April, PM Modi will be able to provide the nation with a strategy based on scientific analysis developed as a result of consultations with states, based on a clear understanding of available resources at the national level. Therein lies the key to solidarity that remains the need of the hour.

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.

Chinese negligence
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.

India’s challenge
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.