Commentary: India’s struggle with COVID-19 could get much worse
India is one of the worst-hit countries in the world as cases have quadrupled in slightly more than a month, says Dr Karthik Nachiappan.
SINGAPORE: Is India succumbing to COVID-19? Media reports have been alarmingly cataloguing the ostensibly troubling state of affairs across the country.
When the coronavirus initially broke in Europe and then the US, India was largely unscathed. To adequately prepare themselves, the Modi government imposed a stiff lockdown in late March that has, more or less, lasted till now.
Despite the lockdown, India’s health system is besieged with new cases. As of Jun 23, India has recorded over 440,000 reported cases making it the fourth worst-hit country in the world behind the US, Brazil and Russia.
JUST HOW BAD IS IT?
The surge is accompanied by dire predictions from epidemiologists that the worst is yet to come.
Ramanan Laxminarayan, Director of the Washington-based Center for Disease Dynamics, Economics & Policy, said in a recent report that India could see a possible peak of 200 million cases by September.
What accounts for the recent surge in cases and what should India do to contain the virus?
Before we get into the weeds, we have to unpack the numbers.
As of Tuesday (Jun 23), about 248,189 individuals - more than half of the COVID-19 cases in India so far - have recovered with reported deaths now hovering around 14,000 or 3 per cent of reported cases.
But the fatality rate is lower if we add the number of asymptomatic cases or those that have had mild or no symptoms.
In just about a month, the number of cases have more than quadrupled from 100,000 in mid-May with Tuesday morning’s update of 14,933 cases in the last 24 hours representing India’s highest single-day spike.
IT’S A LARGE COUNTRY AFTER ALL
The rise in cases, on one level, is expected in a country of India’s size, population structure and where existing comorbidities like tuberculosis, diabetes and heart disease are prevalent.
Absolute number of cases, which are bound to be large in India given the population and population density, yet look less serious when seen from a per capita basis. But this trend of rising cases should continue as the lockdown eases and people return to some semblance of normalcy.
In terms of fatalities, India fares relatively better given the younger population, particularly those under the age of 65 who have either recovered from the virus or managed it better.
So should New Delhi worry about the virus even if mortality rates are low? Yes, because COVID-19 will continue to pose a public health risk until a large number of individuals are infected which makes its control and mitigation critical.
IT COULD GET WORSE
Moreover, the number of COVID-19 cases in India may actually be significantly higher than recorded - given clear gaps in testing and disinclination of some to get tested and treated.
Fundamentally, India is faring poorly in controlling the conditions that accelerate COVID-19's spread, which could seriously cripple its fragile public health system as cases surge.
For instance, some cities like Mumbai, Chennai, Delhi and Ahmedabad have seen spikes in reported cases due to a large number of international passengers returning home.
Around three-quarters of reported deaths have occurred in three states – namely Maharashtra, Gujarat and Delhi. However, as migrant workers return home from overseas and from the large Indian cities, the other states and cities in countries are likely to see an increase in cases as well.
As states like Maharashtra and Tamil Nadu, which have been battling a crescendo of cases, bring down the number of infections, other states like Madhya Pradesh or Rajasthan could see spikes depending on how the disease manifests itself driven by internal migration patterns.
This could lead to differentiated regional and state peaks, which could severely constrain the pace and rapidity of public health response because India could then be dealing with not just a large pandemic but several regional pandemics that require tailored responses.
WOEFUL STATE OF COOPERATION
One way of managing these cascading peaks is by strengthening national and regional health capacities.
Another effective response would be to first, increase testing and second, transfer resources including physicians, nurses, supplies, medicines and ventilators from states where infections are dipping to areas where infections are peaking.
Both these tasks have proven difficult for various reasons.
For one, healthcare in India leaves much to be desired given the state of its chronically underfunded public health system budgeted at about 1 per cent of GDP.
The system is further burdened by how it is organised - a weak primary and strong private tertiary care system, which works against the mounting of an agile response in the case of a crisis.
India also lacks the necessary medical personnel, ventilators, personal protection equipment and hospital capacity required to mitigate the virus.
However, some cities like Mumbai, Chennai and Delhi generally have better capacity and more resources to deal with health crises like COVID-19.
At some point, their capacity and knowledge of having dealt with the virus could be imparted to other states like Bihar, Jharkhand and Orissa where health capacity is wanting.
But it is precisely these major cities that find themselves overwhelmed by the virus leaving them with little opportunity to assist other states.
Delhi appears to be in a critical state with insufficient beds, staff and supplies to cope with an expected surge. Mumbai accounts for nearly a quarter of India’s reported cases and nearly a third of reported deaths. Chennai has re-imposed a lockdown until the end of June to arrest its most recent spike.
Therefore, the scope for states to work with each other to lessen cases is limited.
Another reason why India has not managed to slow down COVID-19 is insufficient testing. Testing is critical to not only identify infected individuals but also isolate the infected and trace those they were in contact with.
Testing has suffered due to incoherent policies, uneven pricing and availability. The RT-PCR nasal swab test, designed by the Indian Council for Medical Research (ICMR), has been the preferred approach but its deployment has lagged given problems around who should be tested and under what conditions.
Initially, New Delhi relied on imported tests which meant prices of about US$60 that thwarted broad-based testing. Recently, however, some states like Maharashtra, Delhi and Karnataka have lowered their prices.
Moreover, since health is a state matter in India, the implementation of mandatory ICMR standards have varied greatly given the disparate capacities of state health infrastructures.
As of Jun 15, India conducted 0.1 tests per 1000 people or around 150,000 tests per day which paled in comparison to South Africa and the US that carried out 0.5 and 1.15 tests per 1000 people respectively.
Going forward, current guidelines that allow testing for people over a certain age, comorbidities and symptoms, should be relaxed to allow for broader testing.
The sooner a test occurs for vulnerable individuals, the quicker the positive cases receive medical attention and, eventually, be weaned off intensive care and hospitalisation.
This scenario could lessen the burden on an already beleaguered health system.
Yet, despite these challenges, there appears to be a concerted national effort to right the tide marked by several positive developments. Some states like Karnataka and Kerala have done far better than others.
Bengaluru’s success is due to careful planning, the timely use of data and effective contact tracing. The oft-mentioned playbook to control the virus in other countries - test, trace and isolate - has worked in Karnataka.
Technologies are also being deployed to track and trace cases. Indian industry is helping augment testing capacities through the production of nasal swabs, tests and antibody detection tests. Private labs are increasingly engaged in testing despite some regulatory hurdles.
The ICMR has also recommended that state governments work directly with private labs to negotiate lower prices as more indigenous testing supplies and kits become available.
Despite these positive strides, the country will unlikely flatten the COVID-19 infections curve because India is dealing with several pandemics, not just one.
Dr Karthik Nachiappan is Research Fellow at the Institute of South Asian Studies at the National University of Singapore. He is the author of Does India Negotiate? published by Oxford University Press in October 2019.