Sunday, 29 March 2020

Asleep at the Wheel – The Looming Coronavirus Catastrophe in India


Asleep at the Wheel – The Looming Coronavirus Catastrophe in India

Written by Dr. Seshadri Kumar, 28 March, 2020


Abstract

India, under a lockdown since March 25, is finally facing the reality of the Covid-19 pandemic. Unfortunately, over the last four months, the Modi government, preoccupied with political priorities, has let valuable time slip out of its hands. Instead of carefully preparing for a disaster as the country has never before seen, by stocking up on face masks, gloves, sanitizers, ventilators, and the like, in the long available time from November 2019 to March 2020, the government has belatedly woken up from its slumber and is frantically trying to acquire these essential items at the eleventh hour, when it is practically impossible to get them at short notice. The government also did not open up the supply of Covid-19 tests beyond a single Gujarat-based vendor for the longest time, and has rejected the applications of several Indian test manufacturers, with the net result that the medical establishment in India is woefully short of Covid-19 tests.

The PM’s knee-jerk lockdown of the country, a last-minute, desperate move to stem the spread of the virus, without adequate preparation of the public, has also caused untold hardship for the tens of millions of migrant workers on the strength of whom the economy runs, as they have been forced to trek it home for hundreds of miles without food, water, or transportation. To cap it all, a woefully inadequate and poorly thought-out financial package will do little to compensate those who are living on the edge, who will be without any money for the duration of the lockdown, and who will probably be reduced to penury or death by starvation.

And, despite all this suffering, it is unclear, given India’s huge population density, how much the lockdown will actually help in slowing down the spread of the virus, even if a lockdown is the only option at this late stage, given the presence of extremely high-density clusters like slums in India.


Nero Fiddling While Rome Was Burning

The ongoing tragedy of migrant workers in India, where tens of crores (100s of millions) of people are walking hundreds of kilometers to get from urban centres, where they have no work and no food, to their villages in states far away, is a prime example of how this government has mismanaged the Covid-19 pandemic in India.

The situation is analogous to that other great tragedy of recent years, Demonetization, where another draconian measure was imposed on the people with no warning and no consultation with experts, causing incalculable suffering.

The same incompetence and indifference to human suffering is on display again in this government.

Many people had been urging the government to take the Coronavirus pandemic more seriously and many had asked for a complete lockdown well before Modi first imposed his one-day lockdown, on 22nd March and, finally, the 3 week lockdown, on 25th. Prominent among these was the opposition leader Rahul Gandhi, who had been arguing for stronger measures as far back as 12thFebruary in a now widely-shared post on Twitter. The counter-point to that was a post from the PM on 19th February, talking about how he loved eating “litti-chokha,” a popular dish from Bihar.

Mr. Modi was sleeping on the pandemic. He had higher priorities to deal with, such as continuing the months-long curfew in Jammu and Kashmir, rebuilding the Ayodhya temple, creating the Citizenship Amendment Act (CAA), toppling state governments ruled by opposition parties, preparing for the introduction of the Uniform Civil Code, demonizing the Shaheen Bagh anti-CAA protest, and other political moves much closer to the heart of the ruling BJP party and its parent RSS. Health issues were not a priority.

Exodus

When the PM finally woke up, it was a bit late. Experts had told him that the virus was about to hit stage 3, the stage of community transmission, unless he did something fast. So, in what appears to have become a pattern with him, without much warning, he locked down the nation.

The result? Daily wage workers who could not support themselves in big urban clusters with no daily pay had no choice but to go back home. All transport has been shut down – buses, taxis, autos, trains. So what do these millions of day labourers do? They walk. With their wives and children. For hundreds of kilometers, without food or water. Many migrant workers, at the time of writing, are still desperately trying to go back home, with no transport option, waiting for promised buses to take them home. See here, here, here, here, here, here, here, and here for images and videos. State governments are doing their best to cope with the crisis, but no state government can provide emergency transportation to tens of millions of workers all wanting to go home at the same time after they have been blindsided by the Central government.

The migrant workers who were desperately trying to go home were even accosted by policemen who made them crawl on their knees, made them do sit-ups, and inflicted other illegal punishments as per their whim — for not obeying the lockdown — without a shred of empathy for their situation. The Indian police has a well-deserved reputation for sadism, and they again proved their character in this time of need for poor people.

Even before all this, as soon as wind of the impending lockdown came, people scrambled into buses and trains to take the next possible trip back to their hometowns. There was mass panic. If social distancing was the goal, then the sight of buses and trains packed like sardines was the very antithesis of this. But of course, one could argue that this was inevitable whenever a lockdown was announced. People will leave urban centres and go home. So we can consider that the lockdown did not begin on the 25th of March in India, but on the 27th or 28th. Given the progress of the epidemic so far, this was extremely unfortunate, and will undoubtedly result in a huge spike in cases in a couple of weeks.

The exodus started even before the full lockdown of the country on March 25th. There was first the one-day lockdown on March 22nd, which people correctly guessed was a harbinger of the full-fledged lockdown. In addition, several states, such as Karnataka, had their own lockdowns which had come into force before the national lockdown. And there were measures taken even before those lockdowns, such as the notice sent by the Bangalore Municipal Corporation saying that it was not safe for people to stay in PG (Paying Guest) accommodations unless the PGs were following strict hygiene rules — which everyone knew they were not. All these actions, while necessary to contain the epidemic, also increased panic

Assume 50 long distance trains in those last few panic-filled days, each jam-packed with about 1500 passengers (that's a total of 75,000 people, which might be a gross under-estimate), spending 30 hours in close proximity to each other, and you have the perfect recipe for multiplication of cases for a highly contagious infection. For context, it is useful to know that the replication number, R0, which is a measure of how many people one infected person will infect in turn, is 2.38-3.28 for Covid-19, as opposed to 1.5 for Swine Flu. Add to this the hundreds of packed buses. So maybe a total of one lakh (100,000) travellers, traveling anywhere between 10 and 40 hours with others in cramped quarters and zero social distancing.

Now these people have gone back to their towns and villages and infected everyone around them, both during their journey home and after their return to their villages and towns.

We are staring at a human catastrophe in India. China, Italy, Spain, France, and the USA will soon be forgotten. We might just lose the older generation in India, given that the mortality rate of the virus for older people is nearly 15%.

For comparison, think of the event said to be responsible for the explosion of the virus in Italy and Spain - a football match between an Italian and a Spanish side on February 19, attended by about 40,000 spectators. At least all of them were in one place. Our carriers are now spread all over the country.

Inadequate Guidance About the Nature of the Lockdown

In his speech on the 25th of March, Modi assured Indians that essential services would not be interrupted by the lockdown. But it was not clear from his speech how that would be possible, because he emphasized multiple times in the speech that no one was, under any circumstances, to leave the home. He left no room for exceptions in his speech. And people take what he says very seriously. His repeated exhortations to all Indians not to cross the invisible “Laxman rekha” (trans.“a line that must not be crossed”) drawn around their homes scared everyone and gave people the implicit message that no one should leave their homes, no matter what.

While Mr. Modi did say that essential services would not be disrupted, the strong emphasis on not leaving the home confused local law and order people, who were not sure whether citizens were allowed to walk on the streets or travel in their vehicles to go to grocery or medical stores and whether people should be allowed to deliver milk, vegetables, medicines, or groceries.

The result was that policemen started beating up people who even had legitimate reasons to be on the road. People who moved around to deliver milk, groceries, or medicines were beaten up by cops. Even today, on the 28th, supply of essentials to the public is not properly in place. Even middle-class families are scared of going to shops to buy essentials, worrying about cops stopping them. Apps like BigBasket have stopped delivering food.

The situation is even more dire for poor families, who do not have any means of transport, and who will have to walk to get food and milk. Worse, they do not have money and cannot get it.

Inadequate Financial Help to Affected People

The government came out with what it called a Rs. 1.7 lakh crore (US $22 billion) relief package for the poor. What did it involve? Among other things, 5 kg of rice or wheat free to each person below the poverty line. But there are two problems with this scheme. One is the difficulty for poor people to go to the nearest ration shop, in the absence of any transport whatsoever. The other is the need for Aadhar (national ID) verification. This is a freebie, so shops have to ensure that nobody uses the benefit more than once. And so they will demand that people verify their identity using their fingerprints. Now we all know the problems with Aadhar. Often the fingerprints do not match (especially for older people), and often, in rural areas, internet connectivity is not very good. So if either of this is a problem for you, then you will not get your extra 5 kg, even if you somehow made it to the ration shop. The side-effect of all this is that the ration shops will have huge stocks of free grain which they will then divert and sell at full price. This is corruption enhancement at taxpayer expense.

The finance minister made the ludicrous statement that to help the poor, the government will give Rs. 500 (about $7) per month to each of 200 million women through their Jan Dhan bank accounts. How bad can tokenism be? You are trying to compensate a person for the lack of livelihood. Many of these daily-wage labourers earn around Rs. 300 a day. And you want to compensate them for the loss of employment for a month by paying them Rs. 500 a month? All this just to be able to tell the world that you have done something? This is, frankly, insulting to the poor. Another similar offering was a one-time, ex-gratia payment of Rs. 1000 to 30 million poor senior citizens, widows, and disabled people. It is too little to mean anything to anyone. And probably the amount of paperwork needed to collect it, along with the ban on transport, will mean very few actually take advantage of even this meagre payout.

Mismanagement of the Medical Aspects

With movement completely prohibited and no way for people without private transport to get anywhere, the numbers of new victims of the virus will not be known properly in the future. Even in normal times, Indians were reluctant to go to the hospital for any flu-like illness. With no way to go to the hospital, and fear of being beaten up, many will simply not report cases until it is too late. We may know about the progress of the Coronavirus epidemic in the future in India only from the deaths because of the lockdown.

The US, the most prosperous country in the world, with a highly developed healthcare system, is already breaking down with inadequate masks even for its doctors and inadequate ventilators for its patients. In Italy, hospitals have run out of room for their patients and temporary shelters are being set up outside hospitals.

With India's extremely poor health infrastructure, what horrors await us?

It might be instructive to look at what the government has done insofar as preparing for this pandemic is concerned, inasmuch as any preparation has been done. Let us first understand what we actually know about this virus from the experience of other countries.

How does this virus kill? It attacks the respiratory system. The patient finds it difficult to breathe. Thick mucus is secreted in the airways and collects in the lungs. This makes it harder and harder for the patient to breathe. The patient tries to cough to remove the fluid in his or her lungs. Because the patient’s lungs are filling with fluid rather than air, there is severe shortness of breath. The patient literally suffocates to death. What happens is that the virus leads to pneumonia that triggers acute respiratory distress syndrome (ARDS), which leads to death.

This is why the virus spreads through throat and nasal secretions. Those in close proximity to a patient or a passive carrier (one who has the virus but exhibits no symptoms) can get it from their nose and throat secretions, as when they cough or sneeze. If these nasal or throat secretions are left on surfaces, as might happen when a person covers their mouth while sneezing and then touches a railing, then anyone who touches the same railing and then touches their mouth or nose might get infected.

These facts tell us how to address the problems of transmission and treatment. Transmission is through aerial droplets from infected people. Therefore, the first line of defence for any medical professional who deals with Covid-19 patients is a face mask that can prevent the virus from reaching his or her nose or mouth. Similarly, so that a healthcare worker does not touch an infected droplet, he or she needs to use gloves while handling a patient.

Secondly, once a patient does get the virus, the key to the patient’s survival is to prevent pneumonia and ARDS. When a patient’s airways are blocked with fluid, he or she has difficulty getting enough oxygen, and so the solution is to have ventilators so that the patient can be given oxygen to survive.

What is India’s supply of face masks, gloves and ventilators, especially for medical professionals? Has the government secured enough of these items and prioritized them for the safety of medical professionals? There is no evidence to indicate that it has. In fact, it was only on March 20th that the government even banned the export of face masks. There has been no attempt to secure face masks for the medical establishment in India in the likely scenario that the number of cases could exponentially rise. In fact, when the epidemic was raging in China, Indian manufacturers were eyeing a bonanza in exports to China, and the government seemed unconcerned that masks that might one day be vitally necessary were being exported to China. This is where alertness in a government is necessary, especially towards an impending national disaster.

What about ventilators? According to an article in The Print, India has about 40,000 ventilators, but this is expected to be woefully inadequate – when the infection goes through the roof, we may need about 100 times as many ventilators. What has the government done about this? Until very recently, nothing. As with everything else concerning Corona virus, the government woke up to the threat only now. On 27th March, there was an announcement that Bharat Electronics (BEL) will be producing 30,000 ventilators. The company was only approached by the government on March 26th. The government also announced that it will be procuring another 10,000 ventilators from another (unspecified) PSU. Keep in mind that nothing has started; the production line has to be set up and manufacturing started, and all this could take a few months.

A private company, Skanray, has said that it will ramp up production and manufacture 100,000 ventilators in two months. This announcement was made just a few days ago. The problem is compounded by the fact that ventilator manufacturers import many of their parts, and most parts are not available today because other countries have imposed export restrictions on these components as they are battling with the virus themselves. This was, therefore, something that BEL should have been tasked with developing a month ago so that the indigenous technology was already available by the time the number of cases started rising. Another company, AgVa, a startup, has been approached by the government, again recently, and the company has said it will be able to provide 5000 ventilators by April 15. Looking at these numbers, it is clear that we are going to be woefully short of our needs when the situation escalates.

Let us look at gloves. As in the case of masks, Indian companies were happily exporting gloves to China in February, and the government was not concerned in the least. A Business Today report dated February 6 mentioned that although the government had enquired about the production capacity of Indian glove manufacturers, it had not asked them to ramp up production. On March 18, in a reply in the Lok Sabha, the government said that it had provided 15 tonnes of medical supplies to China worth Rs. 2.11 crores. As the report said, “Minister of State for External Affairs V Muraleedharan said the medical supplies included one lakh surgical masks, five lakh pairs of surgical gloves, 75 pieces of infusion pumps, 30 pieces of enteral feeding pumps, 21 pieces of defibrillator and 4,000 pieces of N-95 masks.” Even on March 18, the government had not realized the seriousness of the situation. The government was trying to express solidarity with China, without realizing that within a month, India itself would desperately be needing those same supplies. And now, gloves are in extremely short supply all over the world as Malaysia, which manufactures 60% of the world supply of gloves, is under a shutdown.

All in all, this is a very sad and dangerous state of affairs. The central government seems to have woken up to the reality of the virus only a few days before PM Modi’s “Janata Curfew” call on March 22nd, and seems to have started consulting experts and thinking about the problem only after that. Even an order on March 13th including masks and sanitizers in the Essential Commodities Act was done thinking not about how we might need it for the fight in the hospitals and clinics against the Coronavirus epidemic, but rather to reduce prices for consumers who might want to buy these goods.

And this was despite the fact that on March 3rd, the World Health Organization gave a warning to all countries that there was a looming shortage of medical equipment, and advised governments all over the world to increase production of such equipment by 40%. Modi obviously did not get the memo, even though it was reported in all the papers. Even before this, on January 30th, the WHO declared the Coronavirus pandemic a global health emergency. But at the time, the PM and his government were not concerned about anything other than winning the 2020 Delhi assembly elections, which they lost nevertheless. A government's outcomes are directly proportional to its efforts.

What about tests? The government had, until recently, only permitted one company to provide it with tests for Covid-19. Which is this company? It is an Gujarat-based company called CoSara Diagnostics Private Limited, a US-India collaboration of US-based Co-Diagnostics, Inc. (CODX) and Synbiotics, Ltd., a division of the Ambalal Sarabhai group. A report in the Huffington Post said in this regard,

Earlier this month, at a public event in Utah, Co-Diagnostics Inc.’s head of business development, Joe Featherstone, said the company had devised the test in just seven days using advanced computer algorithms rather than the standard process of trial and error, which takes several weeks. Its India manufacturing partner, Synbiotics Ltd, has a track record of manufacturing anti-fungal medication, but no previous experience in making diagnostic kits.

An inspection of the company financials of CoSara and its American parent, CODX, suggests that the COVID-19 test would be CODX’s first ever commercially scaled diagnostic product and India, most likely, its first major market.

While the government has very recently (report dated March 27th) allowed more companies to sell Covid-19 tests, most of them are from China, USA, Poland, and Germany. Only one Indian company, MyLab, was allowed to sell its kits in India. Kits made by thirteen other Indian companies were rejected by the Indian Council for Medical Research (ICMR). This at a time when most countries, such as the US, recognize that one of the major problems is the lack of availability of test kits.

There is a reason why it is important to focus on masks, gloves, ventilators, and the like in terms of the needs of healthcare professionals rather than the common people. This is because when the cases start shooting up and patients start filling up hospital wards, the pressure will be on doctors, nurses, and other medical staff. They will need masks and gloves in abundance to treat the patients. These will run out very fast. They will need test kits to determine who has the virus and who has recovered. They will need ventilators to keep critically-ill patients alive. And if doctors and nurses do not have adequate personal protection equipment (PPE) such as masks and gloves, they will be exposing themselves to the virus. If that happens, many of them may simply not report for work rather than risk their lives. As it is, even with masks and gloves, the virus is infecting many medical professionals worldwide. To treat Coronavirus patients without PPE is to commit suicide.

How Bad is the Situation?

To understand how dangerous the spread of the virus in India was, I plotted the data of the number of cases in India versus the number of days on March 24, 2020, using data from covid19india.org, a crowdfunded initiative. The data was current until March 24. I have not updated this data since then, because once the lockdown is in force, it is my belief that reporting of illnesses will go down because of the inhibitory effect of the lockdown – no autos, buses, or taxis for a person to go visit his or her doctor if he is unwell. I expect a temporary reduction in the number of cases reported, and so I believe the data is only accurate up to March 24.

By plotting the data on a logarithmic scale, it can be seen that the relationship between the number of cases and time is exponential. What this means is that the infection has entered its exponential phase. From the data, it can be seen that the number of cases doubles in roughly 3.5 days. A simple extrapolation tells us that if the number of cases continues to multiply at this rate, we might be looking at more than 50,000 cases by 15th April. The lockdown that is in place now should have a mitigating effect but, as has been seen in other countries, the effects of the transmission that has already taken place (as in the long bus and train journeys prior to the shutdown in India) will have a huge effect, and so cases will continue to rise for a significant period of time. A prime example of this is Spain, which imposed a complete lockdown on March 14th; however, as of the date of writing (28th March), deaths in Spain continue to skyrocket. It is, therefore, reasonable to expect that the number of cases and deaths in India, too, will keep rising even though a lockdown is in place.

Whether it will reach the 22 million cases by 15th May that the chart shows depends partly on the discipline of Indians to maintain lockdown conditions for an extended period of time — again, given Spain’s experience, it is doubtful that the situation will resolve itself in 3 weeks of lockdown. One would expect the number of cases and deaths to continue rising even after April 15, but hopefully they will not reach the numbers that the extrapolation in the graph, which is based on no mitigation efforts such as social distancing, suggests.

Having said that, an important difference between India and Italy or Spain is the population density. While middle- and upper-class Indians live in comfortable homes that are well-separated and can therefore be socially distanced, most of India’s urban poor live in staggeringly crowded places, such as the famous Dharavi slum in Mumbai. People here have no option to socially distance. Often ten people live together in a 10 ft x 10 ft dwelling, and these dwellings are right next to each other, with just 6 feet distance between two rows of homes. If a single person gets infected in a slum like Dharavi, it is hard to see how the entire slum will not be infected. With so many infected people, and without room for them in hospitals, how long before the entire population is infected? Therefore, whether social distancing can be truly effective in slowing down the exponential rate of growth in a country with such densely populated clusters remains to be seen.

Was all this unavoidable? NO.

What would a more prepared and competent leader do?

What Could Have Been Done

The Coronavirus epidemic started in November 2019. That is why it is known as Covid-19, not Covid-20. The Indian government had a head start of four months before things became critical, as they did after March 15th. But the current government and its leader were too busy dividing the country to think of saving it.

One criticism I often encounter when criticizing the government is, “all this is fine, but what else could they have done? Why don’t you tell us what you would have done better?” So, let us look at some of the things the government could have done, well before mid-March, that would have left our country a lot safer and with a lot less pain:

  • Place a restriction on the export of medical supplies, such as gloves, masks, and sanitizers.
  • Ask the major players in India's textile industry to start manufacturing masks.
  • Ask manufacturers to ramp up production of gloves.
  • Ask major Indian manufacturing establishments to start producing ventilators.
  • Arrange for more testing kits and approve more Indian companies that could manufacture Covid-19 test kits.
  • Impose a lockdown a month before it was actually imposed.
  • Inform the country two weeks in advance that the country is headed towards a lockdown, and assure them that there is no immediate danger, but that if there were no lockdown, it would get dangerous. This would allow migrant workers to take transport to their native places in an orderly way, and all this would have been done a long time before the virus had spread so much. This would have avoided any suffering.
  • Make it clear down the chain, from centre to state to city to town to village, that essential services are exempt from the lockdown; that no one is to harass delivery folks of medicines, groceries, milk, and the like.
  • Ensure that home delivery of all essentials would be fully operational at the time of the lockdown, by talking to the heads of various organizations that do home delivery, well before announcing the lockdown.
  • Two weeks before the lockdown, ask all daily wage labourers and other vulnerable groups to go to government offices and get a Rs. 5000 handout to sustain them for the next two months. Tell them also to pick up their 5 kg of free rice or wheat from the ration shops before it is officially unsafe to do so because of social distancing concerns.

Now that would have been a meaningful, well-thought-out response rather than the harebrained, knee-jerk, last-minute response from the government. But that would have required the government to fully think through all these possibilities well in advance of the crisis. With this government, that is like asking for the moon.

What we got instead was five minutes of cacophony at 5 pm on March 22nd by a middle class that was delighted that they could feel good about themselves with just five minutes of empty symbolism. If Mr. Modi really did care about the medical fraternity, he should have provided the tools they are now going to need to fight this disease, not organize a silly and immature spectacle. As things stand, our poor doctors, nurses, interns, wardboys, and other medical professionals are woefully ill-equipped to handle a killer disease, and will be putting their own lives at risk, thanks to a government that has been asleep at the wheel.



Disclaimer: All the opinions expressed in this article are the opinions of Dr. Seshadri Kumar alone and should not be construed to mean the opinions of any other person or organization, unless explicitly stated otherwise in the article.

1 comment:

  1. Many are worried about what will be their situation after the lockdown. It is better to note what experts say as effects of Covid 19 on Indian Economy
    Indian Economy

    ReplyDelete