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After imposing four phases of the countrywide lockdown to curb the spread of the novel coronavirus disease (COVID-19) starting March, 2020, India will begin to ‘unlockdown’ on June 8. The lockdown was imposed to better equip healthcare systems for the fight against the SARS-CoV-2 virus that causes COVID-19.
This entire exercise in the country was one of the longest in the world and involved one of the world’s largest populations.
This has resulted in the emergence of several questions over how equipped healthcare systems became to fight the virus during the lockdown. These questions either remain completely answered, partially unanswered or ambiguous.
1. Is there community transmission of COVID-19 in India?
The biggest question that remains unanswered is that of community transmission: India is the only country that claims there are a ‘cluster of cases’, despite having more than 200,000 reported cases.
Experts — including the Indian Association of Epidemiologists and doctors advising the COVID-19 task force set up by the Union government — said community transmission in the country existed.
Indian Council of Medical Research (ICMR) scientist Nivedita Gupta said last week that sero-surveillance — monitoring the blood serum of a population for the presence or absence of specific substances — was underway in several parts of the country.
A report on this is expected to be released by the end of this week or the beginning of next week.
2. What would the sero-surveillance study show?
This question, however, leads to another one: The sero-surveillance study was supposed to begin early April with the arrival of rapid antibody kits from China.
Despite being validated by the ICMR, the kits did not qualify for the field, prompting the Centre to categorise them as faulty and asking states to stop using them.
ICMR, after a month, on May 12, said it will conduct the study using indigenous enzyme-linked immunosorbent assay (ELISA) kits. The medical body said it will use ELISA kits on 24,000 individuals in 69 districts.
This month-long gap was crucial: Authorities still have not been able to accept or deny community transmission.
3. What is the full extent of the govt’s modelling studies?
The Centre last month presented three modelling studies to claim it averted several more cases and thousands of deaths by imposing the lockdown. Only slides, however, were presented by the government: One slide per study, to be precise.
The full-length studies with their methodologies and assumptions have not been released to the public. There is, thus, no data available to dissect claims made by the Centre.
4. When will India’s case count peak?
The Centre is also quiet on the future projections. It has not yet officially said when the number of cases in the country will reach a peak.
Scientists of the ICMR — the Centre’s nodal agency on COVID-19 control — said the country was “still far away from the peak”, though many independent studies suggest the peak may come in July. Such statements tend to create confusion, as without reaching a peak, the curve of cases does not bend.
5. What has been added to the health infrastructure?
While one may give the Centre the benefit of the doubt when it said the lockdown period was for ramping up health infrastructure, there are no regular updates for the same.
The last figure publicly shared was on May 21. The release, from the Union Ministry of Health and Family Welfare, said there were 2.81 lakh beds dedicated for COVID-19 patients, 1.1 lakh oxygen masks and 31,250 ICU beds.
Despite several requests, however, the ministry never released a state-wise breakup of these numbers. Releasing such figures can be a step towards transparency and also give people a fair idea of beds in their respective states.
Contrast this with a web page of the US Centres for Disease Control and Prevention (CDC): For every state, the page displays a breakup of the number of ICU and isolation beds available and the number occupied, in each state.
It further categorises states into five categories on the basis of bed occupancy and is updated thrice a week.
6. How equipped are the healthcare workers?
The Centre has maintained opacity on not just resource distribution but also human resources. Several reports have emerged on healthcare workers (HCWs) being infected by the virus.
Several reports said 480 HCWs and their family members were infected in Delhi’s All India Institute of Medical Sciences (AIIMS) hospital itself.
This included security guards posted at the institute as well. The ministry’s representative has not stated — in any press briefing — how many HCWs were infected. The Centre has maintained a limiting response, saying only a ‘miniscule’ were reportedly infected.
Several institutions report consistently on infected HCWs. For example, this CDC page, last updated on June 4, said 358 died and 68,522 HCWs were infected in the US.
7. What is India’s R0 number?
There is also no clarity on India’s reproductive number (number of individuals who can be infected by one individual). There have been various estimates, including one done by Sitabhra Sinha, a professor at the Indian Institute of Mathematical Sciences. According to his last estimates, the number stood at 1.22 between May 29 and June 4. For any disease outbreak to ebb, this number should be less than one. The Centre, however, has not commented on this yet.
8. What about other patients?
There has been no assessment on the part of the Centre to explain the impact of repurposing beds in hospitals and shutting down OPDs for patients other than that of COVID-19.
The Centre did issue several advisories to states to see to it that OPDs function as usual — but the ones maintained by government-run hospitals, including Delhi’s AIIMS and others — are not functional et.
There were reports from across the country of patients suffering from chronic kidney diseases, cancer, human immunodeficiency virus and tuberculosis (TB). Patients were denied facilities such as dialysis, chemotherapy, anti-retroviral therapies and TB therapeutics, etc.
9. How badly has vaccination been hit?
India’s vaccination drive hit to a grinding halt during the early phases of lockdown. As many as 80 million children may have been hit globally due to disruptions in routine immunisation programmes, according to an estimate by the World Health Organization and Unicef.
India is yet to come out with an assessment on its own impact and if any extra rounds of immunisation were planned to overcome the gap.
10. How much will reverse migration hurt?
Migrant workers proved to be the Achilles’ Heel for both the Central and state governments. While they have been forced to walk thousands of kilometres, governments did attempt to arrange modes of transport for them. Migrants have been returning to their home states.
Several states, however, including Bihar and Uttar Pradesh, reported a sharp spike in overall cases because several migrants tested positive for the virus.
Bihar has so far reported that more than 3,000 migrants testing positive. It is not known if the Centre, while invoking the lockdown, figured out that mass movement will lead to a spike in cases.
Receiving states have been caught unawares: In Bihar, a 14-day quarantine is mandatory, while in UP, it is not.
The Centre has left this for the states to deal with. It is also not known how states plan to provide migrants employment on the one hand and stop the infection from spreading on the other. The role of the Centre in this is also unclear.
11. What’s the plan post-lockdown?
The curve of cases has been steadily on the rise, as the country plans to ‘unlock’. In a couple of days from now, at least 10,000 new cases are expected to be reported every day: Something widely accepted among experts within the government.
It is, however, not known if the government is planning any change in strategy to deal with riding cases. Any change in strategy could include ramping up testing, changing treatment guidelines or a reconsideration of ‘unlocking’ the country if healthcare systems become overwhelmed.
The government has often repeated in several national and international forums that its response was “pre-emptive” and “graded” according to the situation.
If the situation were to worsen tomorrow — the signs of which are clear — how it will deal with this is something that remains unknown.