Management of COVID-19: A Lesson to be Learned from India

by Ashutosh Riswadkar

While the USA and many of the European countries are struggling with Coronavirus cases, India is showing a consistent and dramatic declining trend in Covid-19 cases. Even with data quality issues, this decline appears to be a fact and is very visible in India. I am more than curious to understand the reasons behind this.

What are they doing right in India that the US is not doing or can learn from? I have done my own research to see if I could answer some of these mysteries. This is by no means a scientific study but here are a few of my own observations based on a variety of sources.

From a high number of over 97,000 cases per day in September in India, the daily cases have now come down by over 80%. It is interesting to note that the daily testing rate has mostly remained steady at above 800,000 tests per day even during this period of declining cases. The possible theory that India may not have adequate testing facilities does not hold water here, since India does have lots of testing facilities. The wild theory submitted by some people that there are more cases because we are doing more testing in the U.S. also does not hold true. The positivity rate in India has dropped from a high of 11% from August 2020 to 1.7% by January 2021. Although the nation-wide rates are declining, there are still pockets of concern in the States of Kerala and Maharashtra. So, India cannot let the guard down and must stay vigilant at all times.

In addition to this dramatic decline in total cases and positivity rates, the number of deaths and ICU hospitalizations rates including cases needing ventilators have also plummeted dramatically. The hospitals, which at one time were almost full to capacity, no longer have any such problems. The country is opening up for business. Even granting for some level of undercounting of these numbers, there are clearly visible signs for undisputed declining trends.

With a population of 1.4 billion and densely populated cities, India has done a phenomenal job in getting the pandemic under control right from the start. Within days, Prime Minister Narendra Modi took a dramatic action of an unprecedented nation-wide lockdown and restricted all incoming international travels. There were quarantine requirements for incoming international travelers with on-going checks and some contact tracing. Periodic nation-wide appeals and addresses by Prime Minister Modi kept the citizens informed and raised the awareness of this grave risk to the nation and the national emergency. Enforcement and citizen compliance to quarantine and masking were generally high. This certainly helped to keep the initial spread to a more manageable level. One major factor that must have contributed to this success is that the Head of the State (Prime Minister Modi) and the Chief Ministers of the various states, although belonging to different parties, were singing the same tune and were working coherently to bring the COVID-19 situation under control. India realized that having differences in opinions or way of handling amongst the various divisions of the Government must be buried when they are dealing with a National emergency. No wild theories such as the use of hydroxychloroquine for the management of COVID-19 were floated. The use of masks was followed uniformly and no one in the Government made fun of the masks. Although the country is now opening up, the compliance with masks still remains generally high in most places, and a pat on the back of the leaders and the population for a good job would not be out of order.

Besides some of the above points mentioned that contributed to the success of this massive project, one should also not forget the following points which worked for hand in hand for the tremendous success:

1. By the time the number of cases started to rise in June/July 2020, more information about possible treatment and therapy protocols started to become available from WHO and other reliable sources. Although healthcare infrastructure in India is not on par with Western countries, hospitals were never overwhelmed completely over long periods because the government built and utilized many temporary facilities to treat and isolate patients who did not require hospitalization or could not isolate themselves.

2. Aggressive screenings and testing were undertaken using rapid testing. This is another major factor in the success of the pandemic control, unlike some other countries where there was massive confusion in testing.  People testing positive but not showing symptoms were quickly isolated.

3. Those who could not self-quarantine at home due to limitations such as close living facilities were provided access to government-managed no/low-cost quarantine facilities.

4. Government and healthcare professionals tried innovative techniques for different things. In Dharavi- one of the largest, poorest, and crowded slum areas in the world located in Mumbai, health authorities used body temperature and oximeters to test oxygen levels to aggressively screen, test, and isolate suspect cases for further testing. Free meals and food rations were provided to people trapped in isolation with no income and no jobs. It was an “all hands-on deck” effort with the cooperation of public health authorities, city politicians, non-profit organizations, and Bollywood actors/actresses. Dharavi slums had already received international attention with the Oscar-winning movie “Slum Dog Millionaire”. The following BBC link is worth taking a look:

5. India has an overwhelming younger population in the age group 21-50 years, much greater than most Western countries. Although chronic health issues such as diabetes and heart ailments are increasing rapidly in the Indian population, there seems to be a higher level of general immunity in the population against viral and bacterial infections. The poor sanitary conditions in India seem to have a lower adverse health impact on the local population compared to any foreign visitor. This probably resulted in lower morbidity and mortality in India’s coronavirus cases. According to recent John Hopkins University data, India’s death rate is an 11.45/100,000 population versus the US death rate of 139.5/100,000 population. This is a very dramatic order of magnitude difference even with accounting for data quality issues in India (population around 1.4 Billion) has close to 11 million cases and around 155,000 deaths compared to over 26 million cases and over 455,000 deaths in the US (population around 330 million).

6. Although not much scientific basis, warmer temperatures might have played some role. Not directly with virus survival but people could remain outdoors, avoiding enclosed spaces and in a better-ventilated environment to reduce people to people spreading the virus.

7. Another thought is about the possibility of a positive impact of tuberculosis the BCG vaccination. BCG vaccination is mandatory under the public health regulations in India. Some studies have suggested that the BCG vaccine may provide some level of immunity against this coronavirus. The BCG vaccine by no means is going to be as effective compared to a vaccine specifically developed to fight covid-19 but it may provide some level of immunity. This fact needs to be studied carefully with scientific studies and further research to confirm this hypothesis and may be an important consideration for continuing effectiveness of new vaccines against new (more potent and contagious) variant mutations of Covid-19.

8. Although not studied scientifically through large scale antibody surveys, there is thinking by some healthcare experts that “localized herd immunity” development may have helped to keep the number low. In addition to the general level of immunity particularly in the younger population, strict lockdown and travel restrictions (until September-October 2020) may have helped control virus spread regionally. The country has opened up in recent weeks with businesses, buzzing supermarkets and schools are open for business. Travel has resumed. A couple of states (Kerala and Maharashtra) are exceptions to this declining trend but the lack of any large surge even after the removal of many of the restrictions and celebrations of major holiday festivals of Dussehra and Diwali provides some credence to this hypothesis.

Whatever may be the reason, known, unknown or mysterious reasons, the decline in numbers is undeniable. This development has given India a much-needed break. Now India has undertaken a very ambitious massive vaccination program for its huge population with a goal to vaccinate 300 million people by July. India is confident to meet this challenge with its own low-cost homegrown Covaxin by Bharat Biotech and large-scale production of Covishield (Cambridge-Astra-Zeneca vaccine) by the Serum Institute of India Ltd. The Serum Institute of India produces 60% of the world’s vaccine supply. In spite of the great challenge of vaccinating its own huge population, India is donating millions of doses of its vaccine to several neighboring countries (even Brazil) at no cost. Pandemic is a global challenge and we are all in it together. India deserves a lot of kudos and recognition for its generosity and “vaccine diplomacy”. In light of “vaccine nationalism” and export restrictions by several countries, this generosity is very creditable and must be noted by the world.

The economy cannot recover without getting a pandemic crisis under control. The success in controlling the spread of coronavirus and massive vaccination undertaking is helping India open up the country and will help recover its economy. The US can certainly learn from India’s success. There are some encouraging developments in the US with ramping up of vaccination efforts and slow decline in numbers but the masking and public health guidelines compliance is still lacking in many places. The U.S. is showing good signs of vaccine acceptance, but there are still inequalities in vaccination access that must be addressed promptly. With the events such as the Super Bowl event where a very large number of people assemble together, there is a great concern of setback from the possibility of these festivities turning into a “super spreader” event. If India with all the challenges of its huge population can bring the pandemic under control, the US can certainly do it if we show more commitment to compliance with public health guidance and discipline.  I hope that some of the U.S. officials will read this article and take whatever necessary measures from my thoughts.

About the Author:

Ashutosh is a retired risk engineer at Zurich North America. After his retirement, he takes care of his wife and spends most of his time playing with his grandchildren. Asutosh says that he is very eager to mentor, collaborate and share his expertise in product and operations liability with others.

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