Making sense of the covid-19 situation in India.

Even the most ardent critic of India or its government (central and state) cannot argue based on absolute number of reported Covid- 19 cases and related fatalities that India has not done well thus far in its fight against the Covid-19 pandemic. India’s population is approx. 17% of the aggregate world population but only has 0.15% of the total reported cases – that by itself is a staggering data that cannot be ignored easily 3 weeks into the crisis in India.  

The lock-down measure taken by the government of India to avert this public health crisis is a bold one. There is no other country in the world to my recollection that has even made an attempt in modern history to lock-down all her people (leave alone 1.3 billion) to protect them. India’s population is not the only issue that makes the lock-down a bold and challenging measure. India is a democratic country and her people have practiced freedom of movement and freedom of speech for 70 years and more, and this practice cannot be altered at the stroke of a pen within hours, days or months by invoking the Disaster Management Act or any other force.

It is for this very reason that in the last 48 hours you have seen migration of workers from urban cities to their homes in rural parts of the country – you cannot fault these people because they perceive the risk of dying of starvation even if they survive the dreaded virus. And it is the same freedom of speech and expression that, unfortunately, has allowed individuals/groups to spread rumours/misinformation and form views without any basis or facts (remember each Indian has an opinion because they have practiced free speech over the years!!! and we are all proud of that!).

Nevertheless, any attempt to limit these freedoms without force, brutality and with adequate economic safeguards to save those whose very rights the Indian constitution guarantees would have to be supported at this stage especially if you consider the extent of the public health crisis.

So, what is the extent of the public health crisis that requires us to limit our freedoms like never before. Consider the following:

• As of now the absolute numbers of Covid- 19 cases in India stands at 908. These numbers are based on the number of people that were tested and not the number of people that are infected as a result of the virus.
• India’s testing capacity is extremely low and consequently, the testing strategy prescribed by ICMR is also narrow compared to other countries. As per the ICMR data, India has tested only 26,798 individuals. This pales in comparison to South Korea, US and Italy that have tested approx. 3.16 lakhs, 1.03 lakhs and 2.07 lakhs individuals respectively as of March 20, 2020. The US has ramped up its testing capacity significantly post that (3.7 lakhs as of March 26 and in absolute numbers more than South Korea).
• In terms of tests per million people, India’s current numbers are even more concerning (but not surprising). As of March 20, 2020 India had tested only 10.5 persons per million people. This number has not moved much in the right direction because the number of tests have not increased substantially since March 20. Italy has tested 3,498 persons per million people. Whilst, in respect of the per million numbers, comparing India and Italy may not be fair, nevertheless it reflects the extent of the potential challenges.
• One could argue that the above assessments are not correct (that is low testing capacity is hiding the real numbers) because of the number of deaths in absolute terms is also low- 20 deaths in India as opposed to 1, 704 in the United States, 9, 134 in Italy and 5, 138 in Spain- some of the hardest hit countries currently (outside China) in terms of absolute number of fatalities. The argument has some merit because it may be easier to hide the symptoms of the virus (in most cases it is mild) but difficult to hide the cause of death and therefore if the number of cases were higher than the reported cases because of inadequate testing, the number of deaths should have revealed the discrepancy.
• It is difficult to fully controvert this line of argument based on the absolute number of fatalities in India. However, one key point is be considered - the fatality percentage in India i.e. the number of reported deaths v. number of reported cases is currently higher than in the US – around 2.3% in India compared to 1.63% in the US. Further, it may not be correct to argue that as the cases increase, the overall fatality rate decreases because of the simple fact that the fatality rate in Italy and Spain are much higher i.e. around 10% or higher. Japan which has followed a narrow testing strategy (similar to India) has a fatality rate of around 3.2% - higher than the US.
• Therefore, the higher death rate can be attributable to only a few things – either we are unable to provide the critical care support when needed or unable to detect the disease at an early stage. Both are a cause of concern.  
• On the number of fatalities, note that although India’s first case was reported on January 30, 2020- stage 2 i.e. local transmissions from imported cases only effectively began around March 10, 2020 (Stage 2 in the US started around March 1, 2020) and therefore, the numbers could reveal themselves only in the coming days.
• Based on the trend of the fatality rate, it is reasonable to state that India will have higher fatalities if the pandemic were to spread (or if has already spread) compared to other countries.           

Given the serious public health infrastructure constraint in India (which hopefully I will be able to cover in subsequent posts) that are required to “flatten the curve” of the cases/fatalities, we have to be extremely vigilant and have to take a multi-pronged approach in averting this crisis of lock-down, isolation, contact tracing, aggressive testing, early detection, aggressive expansion of critical care facilities. The lock-down by itself will surely not be enough. Which to be fair the government is addressing, and civic society is also lending a helping hand. Whether we are successful and are able to maintain our formidable record of overcoming some epidemics/pandemics in recent history (small pox, Nipah) remains to be seen and will depend on our collective action in the next few months (I am not one to believe that the crisis will be controlled within the next 21 days (the basis of my opinion is a matter of another post) and therefore it is best to set accurate expectations and prepare- I along with several others will be the most happiest if this is proven wrong).

Ankit