India's Path To 10 Mn COVID-19 Cases

As the year draws to a close, the pandemic is still raging though promising vaccines have kindled hopes for a better 2021. Currently, the world has recorded more than 75 million cases of COVID-19 and over 1.6 million deaths. This is more than the entire populations of Madhya Pradesh and Goa respectively. India's case count has crossed 10 million--the second highest in the world behind only the US, on December 19.

SARS-CoV-2, the virus that causes COVID-19, has affected nearly all aspects of our lives. So, of course, there was a COVID-19 angle to be investigated in every field from economics to education and not just in medicine and healthcare.

As we wrap up 2020, we look back at how the pandemic and its related events unfolded in India and how we adapted and switched to the new normal of lockdowns, social distancing, self-isolation and work from home.

From China to India

The first reported case of COVID-19 globally was in China, on December 27, 2019. India's first reported case was about a month later on January 30, 2020, in Kerala. The World Health Organisation had termed COVID-19 as a "public health emergency of international concern" on the same day, upgrading it to the status of a pandemic by March 11.

In the first few weeks, Kerala did a stellar job of limiting the spread of the virus thanks to the relentless and dedicated work of the state's frontline workers. These frontline workers were pioneers and headed into the unknown with bravery as they fought this brand new disease which no one around the world knew much about.

Shortly afterwards, India began a lax screening at airports for COVID-19, and ultimately banned incoming international flights on March 22. While some Indians made it back in the nick of time, thousands of Indians were stranded overseas. The Indian government began organising repatriation flights only in May.

In the early days of the pandemic, Mumbai emerged as the COVID-19 capital of India. As 2020 draws to a close, Maharashtra still has the highest number of COVID-19 cases, with Mumbai contributing the bulk of it as the congested metropolis struggled to control the disease. Pune also reported a large number of COVID-19 cases. Karnataka, Andhra Pradesh, Tamil Nadu and Kerala make up the top five worst affected states in the country.

Lockdown and stigma

The early months were also marked by stigmatisation and communalisation of the virus's spread. In late March, a number of COVID-19 cases were traced to an event organised by the Islamic sect, Tablighi Jamaat, in Delhi. It was one of India's first "superspreader events" with the Union health ministry claiming nearly 4,300 cases were traced back to this event.

Many attendees of the Tablighi Jamaat event were arrested around India, but eventually freed by courts who instead reprimanded the police for arresting them without evidence of them spreading the disease. Studies such as this reported the spread of manipulative fake news during the pandemic, constructing a narrative that a particular community was responsible for spreading the disease in India and a petition had to be filed in the Supreme Court asking for censure.

Meanwhile, mass gatherings such as the ground-breaking ceremony for the temple in Ayodhya, political rallies in the run-up to elections and politicians attending weddings violating government's restrictions continued unabated.

There was also widespread fear and stigma around the disease. The stigma led to several possible patients not reporting their symptoms or seeking medical attention. There were several instances across the country of people obstructing cremation of COVID-19 victims, frontline doctors and nurses being forced by landlords and societies to vacate their homes and reports of buildings and houses being physically sealed when cases were reported.

Around the same time as #FlattenTheCurve started trending in April, the government announced that the lockdown was successful and the COVID-19 curve would be flattened by May 16. This never happened.

However, as the lockdown began to be gradually lifted in early June, cases were still rising. Scientists and policy-makers globally were debating whether to allow the virus to spread in such a manner that herd immunity--a situation where a high enough number of people may have already contracted COVID-19 and become immune to it--could be achieved. The World Health Organization (WHO), however, cautioned against this approach.

A crisis for migrant workers

By April, India had a second crisis at hand--the migrant exodus. Prime Minister Narendra Modi's sudden announcement of the nationwide lockdown on March 24, caught urban India's migrant workers off guard. With all work ceased and little savings, millions of migrants streamed out of cities to head back to the safety of their villages. They desperately tried to catch a bus, walk or cycle, in some cases, for thousands of kilometres to return to their villages. India is estimated to have about 120 million rural-to-urban migrant workers. The states that received the most migrants also recorded the most road accident deaths.

News and social media were awash with images and videos of migrants struggling with their families and belongings, as all forms of public transport in the country had been shut down. Finally, 800 special Shramik Express trains were organised to transport at least 1 million people. The central and state governments announced financial aid ranging from Rs 500 to Rs 2,000 for women and the poor but millions could not avail these benefits because of loopholes and oversight in the schemes and those who got the money found that it was not enough.

We reported on a survey of more than 11,000 workers which found that many of the stranded migrant workers had very little food ration and money left. Many had not been paid by their employers during the lockdown. We also reported on how there was no policy to help migrant workers heading back to villages and who might then return to cities and how there were not enough jobs for them as they now tried to balance their lives in their villages.

While this reverse migration triggered fears that the virus might travel from urban to rural India, the stark reality that faced the workers was that their hometowns lacked well equipped healthcare systems.

Price of COVID

COVID-19 has intersected with our private and public healthcare systems, distorting prices and, with it, access to healthcare for millions across the country. IndiaSpend's The Price of COVID series investigated how the pandemic impacted the patients, citizens and the entire healthcare and medicine sector in India.

While high prices of private healthcare and poor infrastructure in the public sector are nothing new, the pandemic exposed many of the systems' cracks. Patients were paying inflated prices for everything from treatment to medical equipment during this pandemic. In fact, personal protective equipment (PPE), which hospital workers wear to protect themselves from COVID-19, has been one of the most expensive items on most hospital bills. Experimental drugs which are being used for treatment were being sold in the black market at exorbitant rates.

These high prices prevailed alongside the Indian government's massive fundraising project under the PM CARES Fund. Our number crunching and investigations showed there was at least $1.27 billion in the PM CARES Fund by May. However, the government has not disclosed the names of donors and their contributions despite several requests by parliamentarians and Right to Information (RTI) applications.

As the pandemic continued to sweep through the country, state governments finally stepped in to regulate private hospital prices. The price caps and regulations, arbitrary at best, varied from state to state.

In these uncertain times, tens of thousands who thought they had the safety net of insurance were in for a shock. Many COVID-19 patients found that insurance companies were rejecting their claims. And in a country where things are already difficult for the differently abled, things got worse as their medical insurance applications were rejected due to their disabilities during the pandemic, leaving them all the more vulnerable.

The non-COVID toll

The single-minded attention on COVID-19 meant that health services for almost all other ailments were neglected because entire staff, infrastructure, equipment, labs, and funding had all been diverted to tackle COVID-19. So, another important dimension to the pandemic is the toll it took on non-COVID-19 health issues.

People in need of non-COVID-19 hospitalisation struggled to access beds in hospitals. People with chronic illness like diabetes and people with disabilities were unable to access their regular treatment.

Women found it difficult to access contraceptives during the lockdown and as a consequence risked unsafe abortions or maternal deaths. The crisis could also potentially push adolescent girls into early marriage or work, revealed work by non-profits in rural India.

Routine health services took a hit during these difficult months, an analysis of government data showed. The pandemic also adversely affected child immunisation, tuberculosis and malaria reporting, blood banks, mental health, hunger and indebtedness.

Both prisoners and jail staff bore the brunt of the virus in crowded jails, and sanitation workers removing medical waste off the streets were not safe either.

Brave frontline workers

PPE is critical for the safety of frontline health workers attending to COVID-19 patients. But the early months of the pandemic were marked by an acute PPE shortage. Several doctors and nurses, especially in the public sector, protested about being forced to work without any protective kits. Instead, the government asked frontline workers to take hydroxychloroquine, an anti-malarial drug, even though there was scant evidence about its efficacy against the deadly disease.

The term "frontline health worker" conjures up images of doctors and nurses attending to patients in COVID-19 wards, but it also includes sanitation workers, who faced serious dangers in carrying out their day-to-day tasks as they continued to do their jobs without any training or information on healthcare and check-ups. Through all this doctors relied on each other for clinical guidance when there was no cure or vaccine in sight.

Cities like Jaipur tried to make things comfortable for their health workers, by actually ensuring PPE, quarantine, timely salary and COVID-19 tests to keep its health workers motivated.

Problems with COVID-19 data

At IndiaSpend, our aim is to unearth and scrutinise publicly available data and make it insightful. We did just that with the pandemic too.

We spotted the '890 Puzzle' in the government's published data of COVID-19 cases. Our reports showed that the government's data on the number of daily tests were changing by a static figure of 890 for many days in April.

Our data analysts also found evidence in numbers that states which tested more, detected more positive cases. Also, in the initial days of the pandemic, fewer tests in India were showing positive cases compared to Italy or the UK, which had a soaring number of cases at the time. In May, data from nine countries, including India, that had imposed a lockdown showed that only India was showing an increase in cases despite the lockdown.

There were also problems with the ways in which data were being represented or interpreted and IndiaSpend tried to answer the question many people asked: Why COVID-19 spiked in some places and not in others?

Just a couple of months back, the AYUSH Ministry, which deals with ayurveda and traditional medicine, released a clinical protocol for managing and treating COVID-19. IndiaSpend studied the evidence presented for traditional medicine and found that much of the evidence cited had nothing to do with studies linked to COVID-19. We also looked at the robustness of clinical trials in India and how medicines had been approved by the government.

Counting COVID-19 deaths

With every subsequent phase of "unlock," India's caseload climbed with the country's total COVID-19 cases (active, recovered and deaths), crossing one million for the first time on July 16, 2020. Correspondingly, India's COVID-19 death toll rose too. Despite India recording 145,136 COVID-19 deaths--third in the world behind the US and Brazil, questions have surrounded how accurately and robustly central and state governments have been reporting mortality data.

IndiaSpend analysed the reported data and laid down the various reasons why it would be difficult to get exact figures for this and also how more precise data could be collected and reported.

Environment of healthcare

In the early months of the pandemic, there was a widespread belief that the virus would not survive in warm countries like India and its spread would be slower. However, this belief was not rooted in science and experts found the evidence for this theory weak.

During the lockdown, millions of vehicles stayed off the roads driving down levels of pollution leading to the hope that this would slow down global warming and climate change. However, environmental scientists quickly pointed out that the temporary reprieve would change nothing and that COVID-19 has shown that our already burdened health systems were weak and could not handle a climate crisis as well. The need of the hour was an increased healthcare budget to tackle climate-related disasters.

Cultural impact

Cultural and religious celebrations were muted this year. After Holi, India's big summer festivals, such as Ugadi, Baisakhi, Poila Boishak, Bihu and Eid were low key due to one of the world's strictest lockdowns imposed in India. With chief ministers appealing to people not to celebrate or celebrate responsibly without mass gatherings while following social distancing and coronavirus rules, Ganesh Chaturthi and Onam were also low key. Durga Puja in Bengal was the first major festival which went ahead despite the state recording a steady rise in the run-up to the festival. Diwali was less noisy and cleaner this year as the National Green Tribunal passed an order restricting the sale of fire-crackers in light of increasing pollution levels, which could have increased the risk of COVID-19.

How to resume normal life?

Scientists and policy makers globally have spent most of 2020 debating how normal life might resume for people around the world. Hope and funding have been invested in a COVID-19 vaccine.

In the meantime, governments have deliberated on whether schools should be reopened for children while scientists have discussed how prone children may be to COVID-19 as opposed to adults and whether children could carry the disease back into their homes. We reported on how some experts think it is fine for us to wait and delay opening schools, how digital learning had stepped in to fill gaps in school education but also how many parents reported that digital learning was not working for their children.

If 2020 was about testing, tracing and treating, 2021 will be about a vaccine for the disease.

As of December 10, 2020, there are 52 vaccine candidates under clinical evaluation in humans. The vaccine from Pfizer-BioNTech has been authorised for emergency use in the US and UK. The UK has also begun distributing it as part of its public immunisation programme on December 8.

Even though a vaccine might be available to us shortly, India would have a tough time vaccinating its adult population against COVID-19 without disturbing its ongoing child immunisation programme. India administers about 390 million doses of various vaccines to children and new mothers annually, and now plans to vaccinate 250 million adults next year. All of this is being done without any announcement so far about improvements in the existing vaccine infrastructure like cold chain and cold storage.

No vaccine or mass vaccination programme could possibly take us back to pre-pandemic lifestyles quickly. Using masks, physical distancing, hand-washing, tracing, testing and treating would continue to be vital, with or without a vaccine, to defeat COVID-19.

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