The numbers seem to indicate that we have COVID-19 under control. Is that the case?

What is the best case scenario and what is the worst case scenario?

There are zero cases from states such as

and Gujarat with large migrant populations. Why?

Do we have the resources to test all people with flu symptoms?

ICMR says it is doing random testing of cases of flu like symptoms. Would that help?

It’s said that community spread is inevitable but can be slowed down. Is it feasible to slow down the spread once it spreads into the community in a country like India?

How well prepared is the health system?

Why can’t we requisition help from the private sector in an emergency for ICU beds and ventilators?

Why do you think we won’t have that sort of hospitalization?

Do you think India has an advantage because of a larger proportion of young population?

Are shutdowns the answer?

What explains the relatively very low number of Covid-19 cases in India? It could be down to inadequate testing, Dr T Sundararaman , public health expert and former Director of the National Health Systems Resource Centre tells Rema NagarajanIt is too early to be sure. And the number of persons we are testing, and the number of laboratories for testing are very low. But the most worrying is that the current whom-to-test protocol will completely miss any community transmission.This is more in the nature of speculation than any scientific estimate. The best-case scenario is that this virus is very sensitive to the Indian summer and decreases completely, and does not come back later. The total infected remains lower than say 10,000. The worst-case scenario is that it peaks in July, when it infects a high proportion of the adult population over 30 years of age, say 30 to 50%, and over 4% of these need critical care.I feel it’s because of extraordinarily low level of testing. Bihar has just one testing centre in Patna, Gujarat two in Ahmedabad and Jamnagar. How can we expect someone with flu symptoms to travel such long distances to be tested? In several states, I was told of instances where people going with flu symptoms to the general hospital are being turned away because there is no testing centre there. Why can’t there be testing centres in at least in the 272 government medical colleges and in district hospitals?In practice they don’t seem to be testing anyone except those with history of travel abroad or of contact with someone who had COVID-19. But if community transmission has set in, which is very likely, the majority of the infected would not have such a history.It’s just a PCR test like you do for other diseases like dengue, HIV, Hepatitis C or drug resistant TB. So scale up and implementation for COVID-19 is possible. There is the issue of bio-safety in handling the samples and that would have to be addressed by rapid training programmes and necessary protocols. The government should procure and make test kits available across testing centres for free in an emergency like this. Having just 52 centres across India makes no sense. And not even all of these are fully functional.Random testing is not the same as testing all people with clinical symptoms of flu. Random testing is usually done at a much later stage for getting population-based estimates of the spread of the disease by testing for antibodies. Right now, they ought to test everyone with flu–like symptoms. South Korea found huge cluster of cases in the most unexpected of places because they did extensive testing. But we seem more inclined to do dramatic things like cancelling all visas, closing all educational institutions etc, but not enough on the ground like setting up testing centres. Even one testing centre per district would mean only about 700 centres, an easily achievable target.All our measures will help slow it down. But the flu happens in surges. It might well go down, if this virus act similar to flu viruses that go down in summer. But there could be a surge when the monsoon starts in July. We buy some time by slowing the spread, but we have to be prepared for the July surge. There is usually one more surge in winter.Going by an estimate that 30 to 50% of a population could get infected and of this 4% would need critical care, we are talking of 25,000 or more in a district of 20 lakh population. We hardly have any ICU beds or ventilators in district hospitals. We need to start setting them up immediately. But we don’t hear anything about district hospitals being strengthened or surveillance for flu and flu-like illness being set up. Once the epidemic is over, we might have surplus capacity of ICUs and ventilators. That’s how a public system has to be. It has to have surplus so that it can expand its capacity in times of emergency. Moreover, India has a large amount of insecticide poisoning and cobra-snake bites, which also requires ventilators. We also have a high incidence of chronic lung disease and seasonal flu, some of whom develop complications for which ventilation would be required. So these facilities can be put to good use.Even the private sector doesn’t have enough capacity, except a few concentrated pockets mostly in urban areas. They will have to be roped in for isolation, quarantine and support services. In a specific district with an outbreak, you might have to commandeer all the private resources. The government has the powers under the Epidemic Act. It needs to have a plan ready on how it can take over all private healthcare resources in an emergency and run it and hand it back once the emergency is over. Someone has to try out the drill, develop a protocol on how to do it; that’s what emergency preparedness is all about. Every chief medical officer of a district ought to know how many beds can be commandeered in a district if needed, what provision for transport exists and so on. But my guess is that we won’t have that sort of pressure for hospitalization.We could get lucky and much less could get infected. But a more likely reason is that we could be in denial since we are not doing enough testing to identify the cases. Access to hospitalization is even now very skewed. Otherwise, why is there such a huge difference between hospitalization rates in Kerala and Bihar. Because the latter doesn’t have systems to capture the data, we cannot measure the excess deaths that are happening due to lack of hospitalization even before this pandemic.Going by the pattern in other countries, because we have a younger population, we should have less incidence. Having fewer old people might mean fewer deaths and so mortality rate might be less. However, whatever advantage younger age gives us would be lost because of widespread malnutrition and chronic respiratory disease. India has a high susceptibility to TB. India’s rate of chronic lung disease is five to ten times higher than developed countries, probably related to its higher levels of air pollution, and this means a higher incidence of respiratory illnesses. However, even if there is a spike in hospitalizations and deaths due to acute respiratory illness, if we are not testing, we will attribute those deaths to the co-morbidities. There is no way to clinically differentiate a death from acute exacerbation of COPD from a COVID-19 death, though COVID-19 could be the cause of the exacerbation, unless you test.Other than mitigating the health impact of the epidemic, we need to mitigate the economic and social impact. We need to be careful about the societal and economic shutdowns. The impact of tourist business, restaurants, travel, etc being shut down is felt hardest by contractual labour living precariously on daily wages. We seem to have no plan to mitigate their loss and no compensation for them. The burden of a shutdown will be borne disproportionately by the poor. If this shutdown prolongs, the adverse impact on their health could be more from the economic crisis and hunger than from the pandemic. If public health expenditure does not rise sharply, more and scarce public health resources would require to be diverted to fight the epidemic and that could mean that it leaves less for treating other diseases that they are dying of.