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Covid: After six months of relative relief, is India about to enter a difficult phase?

With a weak health system, India was expected to do badly during the Covid-19 pandemic. It was assumed that if the fight reached India’s perpetually overcrowded and under-resourced hospitals, there will be massive fatalities. However, even as 43,000 deaths are recorded after six months of the pandemic, with many states showing an intense viral spread, the relatively lower death rates remain a matter of surprise for experts. The cooperation and coordination between India’s central and state government efforts have also surprised many, given political fault lines and tensions.



In stark contrast to countries with strong health systems that were slow to react, India implemented a decisive nationwide lockdown. It provided the time to enhance infrastructure; and coordinate local and central government to develop a system of flexible, localised strategies that adapt to the varying circumstances across India. The Indian policymakers were acutely aware that if the country were to have a fighting chance at containing the virus, they had to stop the clock to prepare for the long-term fight.

Economic lockdown had enormous human costs, particularly for those from the informal sector, but resource transfers and a streamlined public distribution system have tried to ease the situation. Given that a considerable proportion of India lives in overcrowded situations where lockdowns offer limited protection, it was clear that lockdowns will be difficult to ethically defend in the long run.



Therefore, India was quick to endorse face masks too, a measure which will have protected a large number of high-risk populations during the ongoing unlock phase. While countries like the UK took nearly four months since the initial lockdown to make face masks mandatory, large parts of India made face masks compulsory way back in April.

India has also remarkably strengthened its testing capacity, from just about 100 tests daily in February to more than 600,000 tests. Still, it is a fact that India will be testing only a small proportion of its population. As of now, just over 2 crore tests have been conducted and even in cities where up to half the population is suspected to be infected already, total test numbers are just about 5% of the population.

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India has been following a strategy of calibrated tests, forced by the limited resources at hand. Lately, the government has promoted the use of rapid antigen tests, currently about one-third of total tests. It is clear that the effort is to quickly find potential super-spreaders and reduce momentum, rather than try to locate every positive case and stop the virus. With the focus shifting to identify patients with high viral load soon enough to offer early containment and treatment, the ongoing community transmission across most parts of the country is being acknowledged tacitly.

However, two-thirds of total cases are still from 50 districts of the country, most of these highly urbanised. Of all the deaths from Covid-19, two-thirds are men, reflecting the global trend. Only 2% of the dead were aged under 25 years and more than 50% of fatalities were aged above 60. About 87% of fatalities were of those above 45 years, and most of the younger victims had co-morbidities. Also, under 2,000 patients, or only 0.27% of the total active patients are currently on ventilator support.

On May 1, more than 50% of India’s new cases came from three cities — Mumbai, Ahmedabad and Delhi. As of now, these cities represent only around 3% of total cases, as the initial hotspots have reached a plateau. New hotspots have emerged, and with districts from states like Uttar Pradesh, Assam, Bihar and Odisha starting to report higher number of cases, India is entering an even more difficult phase.



As Covid-19 expands to less urban areas, cases as well as deaths may become less visible because of weak health system capacity. Within recorded cases, there is a risk of higher fatality rates, too, with more high-risk populations getting affected. We may see more deployment of railway coaches repurposed as medical wards — hospitals on wheels — as well as the newly manufactured ventilators under the Make in India campaign to the farthest corners of the country to fight Covid-19.

In parallel, India is also emerging as a significant global player on the Covid-19 vaccine scene, with its vast private sector production capacity, making it a partner by default in any major global endeavour. Interestingly, India is not part of the Access to Covid-19 Tools or the ACT Accelerator, a collaborative platform launched by the WHO, the Bill and Melinda Gates Foundation, European Union and the Wellcome Trust for the accelerated development, production and equitable global distribution of Covid-19 vaccines.

Seroprevalence surveys from across India have shown that lockdowns have a limited impact on the spread. The policy aim should be to make sure that high-risk sub-populations are protected, so that deaths are kept at a minimum. India has opted for a graded opening and in this context, mask wearing, physical distancing and hand hygiene are perhaps the best interventions available. To complement these efforts, India’s Covid-19 fighting app, Aarogya Setu, has about 150 million of India’s 450 million smartphone owners using it already.



With physical distancing a luxury many cannot afford, only innovative policymaking through a coordinated implementation of localised strategies will improve India’s chances in this long-term battle. With no Covid-19 vaccine yet in sight for the near future, India is still in the initial phase of the pandemic, and needs to ensure voluntary compliance of best practices by the population through effective risk communication.

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