MATTHEW FEARGRIEVE explains why Health Experts say that India should prepare for the worst. And why the country is not prepared for what is coming.

AS AT 4 APRIL 2020 there are around 2,650 known cases of COVID19 in India, and 68 confirmed deaths across 29 states, reported by the country’s Ministry of Health and Family Welfare (MoHFW) which is working in conjunction with teams at the Johns Hopkins Coronavirus Resource Centre in the United Kingdom. These numbers are changing by the hour and will, unfortunately, be significantly higher when you read this article. Click on the maps and links in this article for up-to-date statistics.

A number of online media have extrapolated the salient regional statistics for the benefit of their readers, for example the Times of India which has modelled an interactive COVID19 tracking map:

The Johns Hopkins Coronavirus Resource Centre has launched its own interactive map, tracking COVID19 cases worldwide:

The Indian government has coordinated the provision by Indian states of food parcel donations to villages, with a value of US$400 per parcel, and is also making food and cash donations to daily wage workers and domestic staff who have found themselves unemployed and homeless after Modi announced the 21 day lockdown.

The challenge for the Modi government on 16 April, at the end of the lockdown, will be to deliver the healthcare needs of the nation. So what are those needs, and what chance does the government have of providing them?

Coronavirus in India: Trajectory?

There is currently no model for projecting the extent of COVID19 mortality across the Indian subcontinent: the landmass is too vast, the Indian states are too different, and so much is still unknown about the virus.

Dr Henk Bekedam, World Health Organization Representative to India, has said that “India stands at an important turning point in its fight against COVID19. Extraordinary situations demand extraordinary measures… ramping up measures to find, isolate, test, treat and trace”.

Though the pandemic is in its early days on the subcontinent, health officials have warned that even facilities in India’s wealthiest states could be overwhelmed by the spread of the virus.

Social distancing & self-isolation

Prime Minister Narendra Modi announced on 24 March 2020 a 21-day nationwide lockdown: “In order to protect the country, and each of its citizens, from midnight tonight, a complete ban is being imposed on people from stepping out of their homes”.

But Modi’s response to coronavirus has been met with fierce domestic and international criticism, sparking as it has the expulsion of hundreds of thousands of workers, now unemployed after having been sacked by their employers, many of which are affluent households in the Indian cities, and who now, with the cities in lockdown, have no alternative but to walk hundreds of miles across country to reach their home towns and villages. They have been beaten by the police and sprayed with disinfectant along the way. And with each step they take, the virus travels with them.

The Indian government’s response to the crisis has generated some distressing images on the TV and computer screens of the developed world, prominent among which were the recent images broadcast by the BBC of elderly people in West Bengal, unable to distance themselves in cramped accommodation from their family, self-isolating in treetops set apart from their family homes.

These stories and images confirm optically the nub of the virus problem in India: overcrowding.

China and European countries have learned — the hard way — that the only known mitigatory measure that can be taken against the virus is to maintain separation between people. The virus is propagated by coughs and sneezes, and so many countries worldwide, including the United Kingdom and the US, are practising what has become known as “social distancing”, which is basically keeping your distance from other people. Those showing coronavirus symptoms or who have tested positive for the disease are required to self-isolate in their homes, if their symptoms are sufficiently mild not to require hospital treatment.

But how does a person maintain social distance from others in a slum, where he or she may share a toilet and a room with tens of other people? This is one of the big challenges that faces the Indian subcontinent. Social-distancing is simply not possible for the majority of its population.

Although people are relatively dispersed in rural areas, communicating information about social distancing in order to change behaviour there will be challenging, if not practically impossible. And unlike the developed world, where ordering food deliveries to one’s home is easily achieved with an internet connection, the vast majority of people in India have to walk into a shop to buy food.

So the virus is likely, if it follows the same trajectory seen in China, Europe and the US- to spread quickly and easily in India. That brings us to the next problem.

Migration of daily wage workers

Since Prime Minister Modi declared the 21-day lockdown, around 25 million of the estimated 100 million migrant workers in India have set out on long journeys, on foot, back to their home towns and villages. They have been beaten by police and sprayed with disinfectant. Many more daily wage workers may attempt the seasonal migration in May and June, ahead of the monsoon.

With each step these migrants take, the virus spreads. And the Modi government does now know how many migrant workers there are in India, let alone where they are at the moment, or where they are headed. Their enforced migration represents a clear and present danger of the virus spreading into the India hinterland, where there are simply no healthcare facilities that can cope with COVID19 cases in any number.

Healthcare

Health-care systems in the country remain weak and will not be able to handle a widespread outbreak. In addition, many people in India have serious health issues — such as HIV, tuberculosis, or acute malnutrition — that make them vulnerable to other illnesses.

Many healthcare systems in the developed world — including those in the United Kingdom and the US- are overwhelmed with severe cases of COVID19. But Indian states are even more vulnerable because they have significantly fewer hospital beds. For example, the most recent data available indicates that Uttar Pradesh and Gujarat each have 0.5 beds per 1,000 people, compared to an average of 5.6 per 1,000 in Europe.

India has limited tertiary-care capacity, including critical care units, and limited medical supplies in many places. There are not nearly enough ventilators, or oxygen-giving equipment, which is absolutely crucial for the treatment of COVID19 patients. This lack of infrastructure is causing problems in Europe and the US. Its impact on India is not difficult to imagine.

HIV in India

Millions of adults and children in India have severely compromised immune systems, mostly because of HIV infection and related tuberculosis. Data on the fatality rate for immunocompromised COVID19 patients is very limited, but early indications suggest that the death rate for individuals with chronic medical conditions is significantly higher than the overall case mortality rate.

Malnutrition

There is widespread malnutrition in India, particularly in infants. Given that the increased risk of mortality from diseases like pneumonia is up to 36 times higher for malnourished children, COVID19 puts this population at significant risk.

Younger population

India is the world’s second most populous country, after China. It is home to over 1.3 billion people (per 2018 estimates made by The World Bank in 2018). However, India is also a young country: half of its population is under the age of 25.

Data from countries that are further along in the pandemic, including China and Italy, consistently indicates a much higher fatality rate among older people (roughly, the over-60s). This could mean that India’s young population could mitigate mortality rates. Over 80% percent of COVID19 deaths in China were in the over-60 group, which accounts for 16% of the population. In India, on the other hand, the same group represents 8% of the continent’s population (per United Nations estimates).

This factor could therefore represent a glimmer of hope that the trajectory of the virus in India will not be as ravaging as some experts are predicting. But it is very much a case of wait-and-see. So what can the Indian government do more to prepare for the spread of coronavirus?

Preparedness

The government of India, unlike others in the developed world, has more experience of mass disease and epidemics. So it is arguably better prepared psychologically than many EU countries have been.

Three critical steps to preparedness can be generalised as follows:

Indian states must work together, as well as implement national strategies. Regional unions can be powerful drivers of that cooperation.

Global groups working to support the pandemic response in India, including UN and WHO agencies, governments, donors, NGOs, and companies, must be co-opted by the Modi administration as effectively and as robustly as possible to help the country tackle the spread of the virus as something that is to the collective benefit of all stakeholders, whether they live in India or not.

Other stakeholders must bring community leaders into the process from the start to build trust and to ensure that people and communities understand and adopt potentially challenging constraints.

Labourers walk home, hundreds of miles across India, after Modi’s lockdown leaves them unemployed

Outlook

So what are the India’s prospects as coronavirus continues to spread and COVID19 cases rise?

If the virus does not, as is hoped, find it harder to spread in India’s relatively young population, then social-distancing, which is practically impossible in vast swathes of the subcontinent, will not mitigate its spread. The only bulwark against the disease that will be available to Indian states, rich or poor, will be their healthcare systems.

If those systems become overwhelmed, the consequences will be broadly as follows. First, deaths among patients with other illnesses could spike. Secondly, public distrust of hospitals and general unease could increase, leading patients who need treatment to avoid seeking care, a social phenomenon seen during the Ebola crisis in Africa in 2014. Thirdly, the capacity of healthcare systems could erode further if large numbers of healthcare workers fall ill with the virus. This is something now (April 2020) beginning to manifest itself in Europe, in particular in Italy, Spain and the United Kingdom, where protective clothing has not been readily available to medical staff in hospitals.

Self-responsibility

A central lesson of the Ebola outbreak in Africa is that people MUST be educated, enabled and — if necessary — forced to take the mitigating steps that the government recommends, such as regular hand washing and avoiding unnecessary social contact. Regional governmental bodies in Indian states and provinces must work hard to ensure that their citizens do not lose trust in community and health organizations that are there to help and support them; irrespective, to some degree, of the efficacy of the treatment that those organizations are dispensing.

Reverse migration?

With an estimated 25 million migrant workers on the roads of India, making long journeys on foot to their home towns and villages, the Indian government must consider the possibility that many of these daily wage workers will not return to the cities from which they have been ejected. This in turn will place additional pressure on healthcare facilities in suburban and rural India, and will leave the manufacturing industries short of labour.

There will be some upside to this reverse migration. The plague of Bombay in the 1890s, when employers were left with severe workforce shortages, resulted in a change of bargaining power in favour of workers, who were able to demand higher wages and better working conditions.

The truth of the situation at the moment is that the Modi government does not know how many migrant workers there are in daily wage jobs in India, and has no idea where they are at the moment or where they are headed. The government has the 2011 census figures on which to base its decisions (the census having been delayed for eight years) and one of the steps that should be implemented following the end of the lockdown is the immediate formation of an inter-state migration council.

Such a body would not only facilitate the coordination of healthcare to the villages, but would also help to monitor how many of the workers who are currently leaving the cities remain in their home towns and villages afterwards. It could be that one of the consequences of coronavirus in India will be a resurgence in the economic activity of smaller hubs outside the cities as workers choose not to return there.

Now the Developed World Must Look India In the Face

For a very long time, widespread, unstoppable disease and pandemics were something unknown in the so-called developed world. The previous pandemic to which much comparison is being made in social commentary in Europe and North America is the 1918 influenza pandemic (the “Spanish ‘flu”) that infected around 500 million people (or one-third of the world’s population) in the early part of the twentieth century. Not since that time has a pandemic had such an impact on the whole world as the coronavirus is having.

Now the developed world may at last truly empathise with the plight of people in India throughout time, as people of all nations now, hopefully, come together in the face of a disease that is no respecter of sex, race, religion or other accidents of birth.

It is an axiom in India that it normally takes a crisis for positive change to come about. It remains to be seen whether the Modi government- or its successor- rises to the profound challenge thrown down by the coronavirus.