Health is a state subject in India, and at the ground level, it is the state governments that are leading the fight against the novel coronavirus in India. However, the most crucial aspects of the policy response to the pandemic rest overwhelmingly with the Centre: restrictions on international travel and exports; screening at ports of entry; testing strategy and criteria; treatment and drug protocols; the global procurement of emergency supplies; and of course, the pivotal question of when, or whether, to impose lockdowns, and in what form.
To what extent state governments have been consulted on these policy decisions is not clear; but predictably, the global and pressing nature of the COVID-19 crisis seems to have further aggravated the imbalance that characterises Centre-state relations in India. Far more so than under a business-as-usual scenario, the Centre holds greater administrative power, while the states bear most of the administrative responsibility (and the consequences of Central policies) in India’s COVID-19 response.
Keeping in mind this ‘make-or-break’ role played by the Central government, here is a critical look at its policy trajectory in the days before lockdown, and what consequences this had:
1. Haphazard travel restrictions and double standards
As early as January 17, India started issuing travel advisories for those flying to China. On February 5, it banned entry for foreign nationals travelling from China to India, although 25 other countries had confirmed several Covid-19 cases by January 31. India waited another month before banning entry to nationals of Italy, Iran, South Korea and Japan on March 3. While Japan had 284 cases on that date, arrivals from several other countries with a sizeable number of cases, including the US (85 cases), France (212 cases) and Spain (166 cases) – faced no entry ban in India.
It was not until March 22, after much confusion and chaos, and with a total of 292,142 cases confirmed across more than 150 countries globally, that India finally suspended all international travel, more than two months after it issued its first travel advisory. More than 15 lakh people had entered India between January 18 and March 23. None of them, including those who entered throughout March, were screened for anything other than high temperature; even though a February 28 WHO report on COVID-19 in China, had acknowledged the possibility of asymptomatic and presymptomatic transmission (wherein some of those infected by the virus display no symptoms, but can still infect others). More recent research suggests the proportion of such ‘silent carriers’ maybe as much as 30% of all infected cases).
The government’s lax approach to international air passengers, at a time when they were practically the only source of infections of COVID-19 in the country, was in marked contrast to its response to the domestic populace. Especially so, with the working poor, who were left stranded by the millions, when the Centre suspended all domestic public transport without notice on March 24 ahead of the 3-week national lockdown. Many were stranded literally thousands of miles from home, and the shutdown triggered a mass exodus by foot, taking a huge toll in lives and livelihoods.
2. Shortage of emergency supplies and red tapism
Personal Protective Equipment (PPEs), especially masks and coveralls, are essential for the protection of healthcare workers, and are mandatory under WHO guidelines for Covid-19 treatment. Masks are required in large numbers also because they are disposable and are the chief means of protection for the general public as well. The Centre had banned the export of PPEs on January 31, the very day India announced its first confirmed COVID-19 case, but, inexplicably, allowed the export of raw materials for PPEs to continue unchecked till March 19. This came three weeks after the World Health Organisation had alerted governments on possible disruptions in the supply of PPEs.
According to a Scroll.in investigation, the government had not placed any substantial orders for PPEs in the one and a half months since its ban on exports. Nor did it issue any specifications on the design, quality and testing of Covid-19 safety gear for manufacturers to start production. Things got ugly when PPE manufacturers’ associations alleged red tapism, excessive centralisation and a lack of transparency in the procurement process, going so far as to accuse the government of “malintentions”. Sanjiiiv, chairman of the Preventive Wear Manufacturer Association of India, told The Quint, “India lost around five weeks in the production capacity of PPEs. If we would have been provided with the specifications and the basic numbers of stockpiling required, we would have set targets.”
As a result, shortages of protective gear have led to clinics shutting down in Mumbai, doctors threatening to boycott work in Lucknow and ambulance workers going on strike in U.P., while in Chhattisgarh, doctors filed a formal complaint about PPE shortages. Reuters has reported how desperate doctors have been using raincoats and helmets for protection.
According to one estimate, in place of the 38 million masks and 6.2 million coveralls that were required in India, only 9.1 million masks and 8,00,000 coveralls were available. The shortages are doubly worrying because they don’t just hamper treatment, but can greatly increase risk of exposure to health workers and the public. Already reports from different parts of the country suggest that increasing infections among doctors and health workers may partly be due to a shortage of PPEs. Malini Aisola, co-convenor, All India Drug Action Network, summed up the situation to The Mint, “The delay in procurement of PPE has already irreversibly jeopardized the public health response to Covid-19″.
The story was not very different with mechanical ventilators; the single most important mechanical equipment needed to tackle a severe respiratory illness such as COVID-19. It is also equipment that is in short supply by default in most Indian hospitals. Paradoxically, as with many such items, India is an exporter of ventilators. It was only on March 19 that the Centre stopped ventilator exports and initiated moves to procure them. Yet another week passed before the government banned the export of ventilator components and other respiratory apparatuses. By then India had reported a total of 519 confirmed COVID-19 cases. According to one estimate, India may require up to 1 million ventilators to deal with COVID-19, and has recently placed an order for 49,000 units, apart from exploring alternatives.
3. Shortage of testing kits and delay in domestic production
Several independent experts have said that India is not testing enough for COVID-19 cases. At least one highly placed official, Dr Girdhar Gyani, the convenor of the Centre’s hospital task force on COVID-19 hospitals, has admitted that this is because of a lack of kits. Presumably as a result, even as infections spread, 123 state-run labs were operating at just 36% capacity, while the 49 accredited private labs managed just an average of eight tests each. This dire situation was entirely predictable, since it was only on March 16 that the government made its first bulk order of one million COVID-19 testing kits from Germany. Not surprisingly, the kits are yet to arrive – as a latecomer, India finds itself at the back of the line with governments the world over scurrying to stockpile testing kits.
The Centre’s attempts to start domestic production of testing kits too have been bogged down by controversy. The approvals process itself was started as late as 23 March, at a time when India had a total of 471 confirmed COVID-19 cases. Adding to this, ICMR guidelines on domestic testing kits issued on March 23, included an inexplicable condition that required domestic testing kits to be approved by the U.S. Food and Drug Administration, what one manufacturer described as a “totally crazy move”. The stipulation added further confusion to an already chaotic situation, since domestic manufacturers had already been asked to submit sample kits for validation by the National Institute of Virology, Pune.
4. Extremely low testing rate
Perhaps the most controversial aspect of the Indian government’s COVID-19 response is its testing policy, which has ensured that India is conducting fewer tests than most other countries.
India has tested at a rate of 10.5 tests per million people, so low a figure that leading countries were testing at rates hundreds of times higher than India; South Korea (600 times), U.A.E (1200 times) and Iceland (2600 times). At least one public health expert has gone on record to say that the tests administered by India so far “may not be adequate even for a district”. Chhattisgarh Health Minister T S Singh Deo has demanded formally that the ICMR expand its testing regime, which he said is necessary to contain the pandemic. On April 9, the ICMR did finally agree to broaden the criteria somewhat.
Aggressive testing is the only way to track the spread of infections in a rapidly progressing pandemic. The official numbers of confirmed cases and deaths are also psychologically the most crucial factor in shaping the urgency, scale and texture of our response to the pandemic. The uncomfortable fact is that the official COVID-19-related numbers, a product of India’s extremely low test rate, are practically worthless, and may have irreparably compromised India’s response by creating a false sense of reassurance. Add to this, the fact that the low test rate itself is a result of a shortage in test kits.
5. Lack of transparency and denial of community transmission
One particularly serious fallout of India’s testing strategy is the issue of community transmission. As this writer has pointed out, even as the ICMR was assuring the public that community transmission of COVID-19 was not yet detected in India, it had failed to mention that until very recently, it was not even testing for it – or at any rate, not nearly enough. In fact, hospitals were turning away patients with COVID-19-like symptoms – simply because ICMR’s then guidelines offered no provision to test them. To what extent this policy, which was changed only as late as March 20, has contributed to the spread of infections is anybody’s guess. In spite of this, the Union Health ministry continues to deny the presence of community transmission in India till date, despite inadvertently acknowledging it as early as March 5.
It’s worth noting here that a lockdown is primarily a strategy to prevent community transmission. Timely detection of community transmission is the single most important factor that decides when a lockdown is to be declared, what form it should take, or indeed, whether to have one at all. Independent experts have suggested that community transmission may have taken place in India as much as a month ago. Hospital task force convener Gyani even admitted as much, telling The Quint on March 28 that, “Yes, we are calling it Stage 3. Officially we may not call it – but it is the beginning of Stage 3 (community transmission).” What this suggests is that the timing, scale and severity of India’s national lockdown, described as harsher than any other, may have been decided without any sound scientific basis.
What this implies
Earlier this month, Dr Michael J Ryan, the executive director of the WHO, delivered a stark message to the world’s governments on the fight against the coronavirus. “You must be the first mover. The virus will always get you if you don’t move quickly. If you need to be right before you move, you will never win,” he had said, adding, ““Speed trumps perfection. The problem we have at the moment is that everyone is afraid of making a mistake. Everyone is afraid of the consequence of error. But the greatest error is not to move.” As it turned out, this warning went largely unheeded in India.
At a time when nations way better equipped in terms of governance, resources and infrastructure are struggling to contain the COVID-19 pandemic, India, with its exceptionally large and dense population, its poor public health infrastructure, is in many ways uniquely disadvantaged to deal with it. That was all the more reason for the government to have acted early, decisively and transparently on matters that were well within its power, and when there was time to act.
The string of administrative failures that are being revealed suggest that India’s crippling national lockdown may be – among other things – a tight lid placed over a can of worms. As questions about the government’s lapses grow louder (For example, see these ten questions raised by a group of health journalists), the official response so far has been negative: including attempts to place curbs on reporters at official press briefings and, worse, to legalise censorship.
However, given the potentially disastrous consequences, and the need to prevent such failures from repeating, the need of the hour is for more – not less – public and media scrutiny to be brought to bear on the policy decisions on COVID-19.