India has been under a nationwide lockdown since March 25 to contain the spread of Covid-19, with some restrictions being eased on April 20 in regions that aren’t hotspots.
But this measure will not end the pandemic. “The virus will continue to spread,” said Richard Cash, senior lecturer on global health at Harvard University, during a webinar on the response to Covid-19 in South Asia. “Once the lockdown is lifted, a surge is inevitable.”
The country has so far recorded over 26,490 cases and more than 820 deaths. Among the reasons for isolating people, closing businesses, and banning domestic and international travel for weeks on end was to reduce the disease’s spread and allow the country to become better prepared.
But the fact remains that given the state of the health infrastructure—the nation needs more respirators, ICU beds, physicians, and nurses—”every day is a surge day in the Indian hospital system,” according to Cash.
Varied response
A continued lockdown, Cash said, is not the answer for India and other South Asian nations in their fight against the pandemic, and future intervention must take into account demographics, health infrastructure, and resources in these countries.
In the US, there are about 92 people per sq mile, or 36 per sq km. The median age is about 38 years old, and physical distancing is possible to observe. In India, on the other hand, the population density is 460 per sq km, and in Bangladesh it’s 1,240.
A large part of the rural population in South Asian countries lives in close quarters with as many as five people having to share a single room.
Moreover, the average age in India is about 29 years old. It has a much younger population, with approximately 28% below the age of 14. In the US, this figure is 18%.
A mere 6% of India’s population is above the age of 65, while in the US 17% is. This figure is important because most of the deaths—80%—due to Covid-19 in the US have been among those 65 and older.
The response to a pandemic is affected by such variables, and globally countries have responded accordingly. South Asia, however, “should not try to mimic systems in the US where they spend $11K/capita on health, whereas a country like India spends only $75/capita,” said Cash.
The levels of testing in India are also in stark contrast with those in Europe or East Asia.
Inadequate testing
The nation of 1.3 billion has so far tested 4,47,812 samples, and of these, 19,984 have been positive. This is a testing ratio of just over 200 per million. While India has scaled up its efforts—from 1,229 tests on March 20 to 27,824 on April 18—it remains woefully behind several other nations.
Germany, for example, is conducting 15,730 tests per million, Italy 14,114, and South Korea 10,564.
India is facing criticism for its seemingly low testing figures and is being urged to follow in the footsteps of other nations by exponentially ramping up testing.
The Indian Council of Medical Research, however, has countered by responding that it is continuing to test despite only one in 24 samples coming out positive.
According to Cash, widespread testing alone is not the bedrock of epidemic containment.
K. Srinath Reddy, president of the Public Health Foundation of India, agrees: “Testing shouldn’t be the sole mantra that we should be depending upon.” The same testing logic shouldn’t be applied to India as we do to other countries, he said, adding, “We need to have differentiated approaches in our own context.”
Moreover, he said, testing is not a guide to treatment, but only for decisions related to isolation: “Treatment is guided by the clinical condition and is not virus-specific, in the absence yet of proven treatment for Covid-19.”
Reddy suggests looking at it as a pyramid. The serious cases of Covid-19 that require hospitalisation would be at the top. The middle would be infected persons among those who are self-isolating themselves, while the asymptomatic or minimally symptomatic cases would be at the bottom.
“Testing may not be able to get to the bottom of the pyramid, but household syndromic surveillance for an ‘influenza-like illness’ is taking place in many states—that’s giving you the middle,” he said.
Moreover, according to him, large-scale testing isn’t a sensible goal for India given the need for testing kits, protective gear, sample collection paraphernalia, and so on. “We cannot test the whole or even half the population without exhausting the financial and human resources of the health system,” he said.
Asymptomatic cases
There’s an added concern for India: Nearly 70% of Covid-19 positive cases have been asymptomatic—not showing any symptoms of the disease. The health ministry says it’s tackling these cases through community surveillance and contact tracing.
The Indian Council of Medical Research is currently testing the asymptomatic direct and high-risk contacts of a confirmed case. In addition, all symptomatic healthcare workers are being checked along with patients with severe acute respiratory illness (fever and cough and/or shortness of breath).
Some experts, however, believe that identifying asymptomatic patients would be difficult without ramping up the testing strategy.
According to Reddy, asymptomatic persons should be tested only as part of a random sample. “Also, a negative antigen test is no warranty that the person cannot get infected two days or a week later,” he said.
However, as India inches toward the final days of its lockdown, and without the capacity for widespread testing, what all can the country do to contain the spread of coronavirus?
The way forward
India, with its vast epidemiological and social-cultural diversity, cannot have a singular policy going forward. The lockdown has helped reduce the disease’s spread and given an opportunity to strengthen the healthcare response at all levels.
The country is now better equipped in terms of its hospital capacity, procuring personal protective equipment (PPE), and getting more ventilators despite huge global demand.
“Time has been made for preparing,” according to Reddy. “But ultimately, this battle will have to be fought at the primary healthcare level.”
Release from the lockdown, he said, should be staged and differentiated across India, with district-wise decision-making.
There should be a selective reopening of work streams, commercial establishments, and educational institutions initially, with farming, essential goods production, and school education among the first to be resumed.
According to Reddy, to help low-income communities practice social distancing as much as possible, “the government should make arrangements for housing and uncrowded public transport, commandeering vacant buildings and unused vehicles if needed.”
Planning should then take place at the state level, but when it comes to implementation, the process should be undertaken at a district level: profiling of each district to determine whether it is hot, warm, or cold in terms of infection spread.
Community-partnered primary health services and expanded hospital capacity, especially at the district hospital level, must be prioritised. Stressed health workforces must be augmented by training and employing young persons—especially from slums and low-income communities—to become part of the frontline health workforce in their own settings.
Surveillance must be expanded, through a combination of household surveillance for influenza-like illness and an expanded package of testing for viral antigen and responsive antibodies.
Additionally, while wider-scale testing would be needed in the days to come, Reddy says that it should not be seen “just as a game of numbers but as part of a multi-component public health strategy.”
Here are some state models that have proven effective in India which other parts of South Asia could emulate:
Kerala: The state has achieved “excellent success in control despite a low testing rate compared to international averages,” Reddy said. Kerala has nearly 440 confirmed coronavirus cases with a 70% recovery rate, the highest in the country, and has managed to flatten the curve.
In early February, the state formed guidelines on testing, quarantine, hospital admission, and discharge criteria. Soon after it expanded its healthcare capacity, converting a number of defunct hospitals into Covid-19 facilities.
According to an Indian Express report, a critical factor has been the state’s rigorous surveillance network. Besides contact tracing, Kerala has been geo-mapping those under observation for improved cluster management.
Besides the state-level efforts, the social sector has played a significant role in aiding the fight against coronavirus, with volunteers helping to make masks and provide food packets to those in need through community kitchens.
“Community participation has worked to a great extent in Kerala where the local panchayats and volunteers have been taking part in contact tracing as well as providing a lot of services,” Reddy said. “Kerala has been a model of humane and effective epidemic response.”
Andhra Pradesh: The state deployed tech-based solutions such as an app to monitor the location of those under home quarantine and to track the travel history of those who tested positive. Andhra Pradesh also did extensive contact tracing.
Moreover, 2.60 lakh volunteers were selected to serve at village and ward levels. They helped conduct house-to-house surveys to identify cases.
“For every 50 houses at village or ward level, there is a citizen volunteer, who has been teaming up with frontline health workers,” said Reddy.
They carried out a survey of foreign returnees after Feb. 10, conducted comprehensive fever surveys periodically in all households allocated to them, and performed contact tracing. The second level of response, involving the medical team’s visit, followed the initial assessment by the frontline team.
Odisha: The eastern Indian state has won fame in the past for its efficient response to natural disasters such as cyclones. It put that experience to good use in responding to Covid-19—which it classified as a “disaster.“
It was the first state to impose full lockdown and the first to announce exclusive Covid-19 hospitals and set them up within a week in two districts. “It is also offering free treatment to all Covid-19 patients, and has used a strong IT programme to identify and quarantine international and domestic returnees,” said Reddy.
Rajasthan’s Bhilwara: The “Bhilwara model” involves a complete curfew, followed by house-to-house surveys to check for cases, contact tracing of each positive case, large-scale testing, and prevention of travel.
It became the model for other districts in Rajasthan and other states. Kasargod in Kerala followed a similar model with remarkable success.
“These examples of community participation ought to be emulated across the region,” according to Reddy. “We should look at the future with a certain degree of hope, should plan better, and critique when necessary.”