The Trends Shaping The Post-Covid World

Published in The Hindu on 11th May, 2020

The COVID-19 pandemic began as a global health crisis. As it spread rapidly across countries, country after country responded with a lockdown, triggering a global economic crisis. Certain geopolitical trendlines were already discernible but the Covid shock therapy has brought these into sharper focus, defining the contours of the emerging global (dis)order.

The first trend which became clear in the aftermath of the 2008 global financial crisis is the rise of Asia. Economic historians pointed to its inevitability recalling that till the 18th century, Asia accounted for half the global GDP. The Industrial Revolution accompanied by European naval expansion and colonialism contributed to the rise of the West and now the balance is being restored. The 2008 financial crisis showed the resilience of the Asian economies and even today, economic forecasts indicate out of G-20 countries, only China and India are likely to register economic growth during 2020.

Asian countries have also demonstrated greater agility in tackling the pandemic compared to US and Europe. This is not limited to China but a number of other Asian states have shown greater responsiveness and more effective state capacity. Consequently, Asian economies will recover faster than those in the West.

The second trend is the US retreat after a century of being in the forefront of shaping the global order. From the Treaty of Versailles and the League of Nations after World War I or the creation of the UN and Bretton Woods institutions after World War II, leadership of the Western world during the Cold War, moulding global responses to threats posed by terrorism or proliferation or climate change, US played a decisive role.

US hubris and arrogance also generated resentment, more evident in recent years. Interventions in Afghanistan and Iraq have become quagmires that have sapped domestic political will and resources. This is the fatigue that President Obama sensed when he talked of “leading from behind”. President Trump changed it to “America first” and during the current crisis, US efforts to corner supplies of scarce medical equipment and medicines and acquiring biotech companies engaged in R&D in allied states, show that this may mean America alone. Moreover, even as countries were losing trust in US leadership, its bungled response at home to the pandemic indicates that countries are also losing trust in US competence. US still remains the largest economy and the largest military power but has lost the will and ability to lead. This mood is unlikely to change, whatever the outcome of the election later this year.

A third trend is EU’s continuing preoccupation with internal challenges generated by its expansion of membership to include East European states, impact of the financial crisis among the Eurozone members, and ongoing Brexit negotiations. Threat perceptions vary between old Europe and new Europe making it increasingly difficult to reach agreement on political matters e:g relations with Russia and China. The trans-Atlantic divide is aggravating an intra-European rift. Rising populism has given greater voice to Euro-sceptics and permitted some EU members to espouse the virtues of “illiberal democracy”.

Adding to this is the North-South divide within the Eurozone. Strains showed up a decade ago when austerity measures were imposed on Greece, Italy, Spain and Portugal a decade ago by the ECB, persuaded by the fiscally conservative Austria, Germany and the Netherlands. ECB chief Christine Lagarde’s press statement in end March that “ECB is not here to close spreads” undermined any solidarity that the Italians felt as they battled with the pandemic and growing borrowing costs.

Further damage was done when Italy was denied medical equipment by its EU neighbours who introduced export controls leading to China airlifting medical teams and critical supplies. Schengen visa or free-border movement has already become a victim to the pandemic. EU will need considerable soul searching to rediscover the limits of free movement of goods, services, capital and people, the underlying theme of the European experiment of shared sovereignty.

A fourth trend, related to the first, is the emergence of a stronger and more assertive China. While China’s growing economic role has been visible since it joined the WTO at the turn of the century, its more assertive posture has taken shape under President Xi Jinping’s leadership with the call that a rejuvenated China is now ready to assume global responsibilities. Chinese assertiveness has raised concerns, first in its neighbourhood and now, in the US that feels betrayed because it assisted China’s rise in the hope that an economically integrated China would become politically more open. In recent years, the US- China relationship moved from cooperation to competition and now with trade and technology wars, is moving steadily to confrontation. The pandemic has seen increasing rhetoric on both sides and with the election season in the US, confrontation will only increase. A partial economic de-coupling had begun and will gather greater momentum.

Xi has engaged in an unprecedented centralisation of power and with the removal of the two-term limit, has made it clear that he will continue beyond 2022. His signature Belt and Road Initiative seeks to connect China to the Eurasia and Africa through both maritime and land routes by investing trillions of dollars in infrastructure building as a kind of pre-emptive move against any US attempts at containment. Even if Xi’s leadership comes under questioning, it may soften some aggressive policy edges but the confrontational rivalry with US will remain.

Global problems demand global responses. With Covid-19, international and multilateral bodies are nowhere on the scene. WHO was the natural candidate to lead global efforts against the health crisis but it has become a victim of politics. Its early endorsement of the Chinese efforts has put it on the defensive as US blames the outbreak on a Chinese biotech lab and accuses Beijing of suppressing vital information that contributed to the spread. UN Security Council, G-7 and G-20 (latter was structured to co-ordinate a global response to the 2008 financial crisis) are paralysed at when the world faces the worst recession since 1929.

The reality is that these institutions were always subjected to big power politics. During the Cold War, US-Soviet rivalry blocked the UNSC on many sensitive issues and now with major power rivalry returning, finds itself paralysed again. Agencies like the WHO have lost autonomy over decades as their regular budgets shrank, forcing them to increasingly rely on voluntary contributions sourced largely from Western countries and foundations. US leadership strengthened Bretton Woods institutions in recent decades (World Bank spends 250% of WHO’s budget on global health) because US’ voting power gives it a blocking veto. The absence of a multilateral response today highlights the long felt need for reform of these bodies but this can’t happen without collective global leadership.

The final trend relates to energy politics. Growing interest in renewables and green technologies on account of climate change concerns, and US emerging as a major energy producer was fundamentally altering the energy markets. Now, a looming economic recession and depressed oil prices will exacerbate internal tensions in Gulf countries which are solely dependent on oil revenues. Long standing rivalries in the region have often led to local conflicts but can now create political instability in countries where regime structures are fragile.

A vaccine for the Coronavirus possibly by end-2020 will help deal with the global health crisis but these unfolding trends have now been aggravated by the more pernicious panic virus. Rising nationalism and protectionist responses will prolong the economic recession into a depression sharpening inequalities and polarisations. Greater unpredictability and more turbulent times lie ahead.

A Long Road Ahead

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.

What India Needs On 14 April

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.

India’s Lead Time on COVID-19 Is Running Out

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.

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
days.

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.