On May 19, a day after India began to ease the lockdown and open up, the total number of infections in the country crossed one lakh. In the last 24 hours (May 19-May 20), 5611 fresh cases were reported in the country; in the previous weeks, this number had risen from an average of 3,000 per day, to an average of 5,000 per day.
In the coming days, the number of infections is expected to rise further. A section of experts including those in the government say a peak is anticipated in June and July. In April, the central government’s own “post lockdown scenario” had projected 65,000 cases by May 15, and 2.74 crore cases by August 15.
Fresh cases have also been reported across the world in several countries readying to lift lockdowns and return to normal life.
“The virus may never go away,” Dr Mike Ryan, executive director, WHO’s health emergency programme has said. And member countries are only beginning to realise how, as new clusters of infections have been reported in South Korea, and the city of Wuhan in China, even after lockdowns were lifted and people started to step out.
In India, however, the epidemic curve is yet to flatten.
The numbers have been rising, but the distribution of cases has been concentrated in a few areas. According to the health ministry, bulk of cases (80 per cent), have been found in 30 municipal areas in 12 states. The list includes Greater Mumbai, Greater Chennai, Ahmedabad, Thane, Delhi, Indore, Pune, Kolkata, Jaipur, Nashik, Jodhpur, Agra, Tiruvallur, Aurangabad, Cuddalore, Greater Hyderabad, Surat, Chengalpattu, Ariyalur and Howrah, to name a few. States such as Maharashtra, Tamil Nadu, Delhi, Gujarat, have been getting some of the highest numbers of cases.
“India may not have one peak; there could be several peaks. For instance, the Delhi congregation cluster in April was one spike, after which the situation stabilised,” said Dr Prabhdeep Kaur, physician and public health expert with the National Institute of Epidemiology, Chennai.
More importantly, Kaur emphasizes that from a state, or even national perspective, the absolute number of cases don’t mean much. “The numbers may be rising, or falling, but they don’t tell us where to focus. In a state such as Tamil Nadu, for instance, the number of cases have gone up, but if we look at district-wise data, we find that in 80 per cent of the districts, the cases have gone down. So, we need to look at localised data; zero-in on the wards, taluks, even at a particular street where the cases are rising. And then take action on that data, mark that area as a containment zone,” says Kaur. Kaur also said that states shouldn’t fear rising numbers, more case detection would only allow states to focus their action.
Until now, the Centre’s strategy had been based on drawing up a list of red, orange and green zones, depending on the number of cases. However, with its latest advisory, issued on May 17, the health ministry has allowed states some space – they can now categorize the colour-coded zones themselves, as well as designate specific areas such as sub-division/ward, or any other appropriate administrative unit -- as opposed to entire districts as red, orange and green zones.
This, the ministry has said, should be done after considering the geographical spread of cases, contacts and their zone of influence in terms of disease spread. The ministry also provided the criteria for states to assess “critical” and “desirable” situation while defining the zones – based on the total active cases, active cases per lakh, case fatality rate, number of tests per lakh and sample positivity rate.
In the meantime, though, in a bid to curb rising numbers and a rush to move from being red to green, certain districts reduced testing, state officials told THE WEEK. The health ministry’s latest criteria for tests per lakh population stands at 200. According to COVIDindiaupdates, a volunteer driven tracker for India, few states such as Tamil Nadu, Maharashtra, Delhi, Andhra Pradesh, Rajasthan, were over the recommended 200 tests per million, while the states of Uttar Pradesh, Bihar, MP, West Bengal were lagging.
A doctor with a medical college in the Chhattisgarh government said that India had lost crucial time. “Time was wasted in February, and the subsequent lockdown has only served to protect the upper and middle classes while allowing the disease to spread among the poor in urban slums where social distancing means nothing,” he said.
The health ministry, too, has outlined that managing the disease in urban settlements – that houses about 17 per cent of the urban population, according to the 2011 census, a number that would have increased exponentially in the last decade -- will be a huge challenge, given the “overcrowding” and “gaps” in healthcare services in these areas. Disease surveillance systems are also not as “well-organised” as in rural areas, according to the health ministry. An action plan, with an “incident commander” who reports to the municipal commissioner and health workers such as Ashas and ANMs has been drafted by the ministry for these areas.
With the numbers rising due to migrant movement from cities to villages, the strategy would now have to focus on effective quarantine and testing of the returnees. “We need to focus on districts that have a few cases. If we can aggressively trace the contacts in those cases, we can contain the spread,” said the doctor. Once the disease reaches the community, it’s very difficult to contain it, experts say.
Even as active case count is rising, the health ministry has said that India’s recovery rate has been going up consistently. On May 20, recovery rate stood at 39.6 per cent, and according to Dr Randeep Guleria, director AIIMS, the rate would eventually go up to 90 per cent. This, he said, is because majority of the cases in India have had mild to moderate disease. The ministry’s new discharge policy that mandates no test before discharge for mild and moderate cases has also significantly pushed this rate up.
The ministry has also said that India’s death rate is among the lowest – 0.2 deaths per lakh population, compared to the world’s average of 4.1 deaths. However, experts dispute the low mortality rate in India. In India, away from the cities, the cause of death is seldom recorded properly, even at the best of times. In remote areas, many poor people with a severe illness choose to die at home when faced with the choice of unaffordable private healthcare and overcrowded public hospitals. “The current difficulty in taking patients to hospitals during the lockdown makes the death data even less reliable,” the expert said.
In Delhi, a patient brought dead to the hospital will henceforth not be tested for COVID-19, and considered a COVID death only if the patient had been tested positive for the disease before being brought to the hospital and was alive when he tested positive.
In the coming months, India’s disease managers are up against two killers – COVID-19, and poverty. In the absence of vaccine, how states and district administrators will balance the tightrope walk will determine whether – and how soon – India can win the war against the virus.
