Based on the current trend line of active cases, the growth may be slowing but India will hit its peak only when daily recoveries outpace new cases. There are signs this may be happening in Delhi, which is why other metros need to pay attention to its strategy.

A woman watches as healthcare workers wearing personal protective equipment (PPE) check the temperature of residents of a slum during a check-up camp for the coronavirus disease (COVID-19) in Mumbai, India June 17, 2020. Photo: Reuters/Francis Mascarenhas

Just over a  week ago, Prime Minister Modi asked his ministers to prepare “emergency plans” to deal with the spike in COVID cases in the five most severely affected states of the country. If one is looking for an admission from the government that its lockdown had failed, then this is it: instead of taking 21 days, Modi’s Mahabharata has lasted over 100 days. And the battle is only growing more intense by the day.

So how long will it last? How long before the case count reaches its peak and starts to decline? After how many deaths? If anyone in the government has an idea, she or he has kept it a deep secret. Mercifully, we have enough data now to make a reasonable estimate by ourselves. The news is not all that good, but the data on the rate of growth of active cases (i.e. total cases minus those who have recovered)  is sufficiently reassuring to make panic unnecessary. While across India, daily new cases are outpacing daily recoveries, the picture in Delhi is somewhat reassuring and could serve as a guide for what needs to be done if the duration of the pandemic is to be shortened.

The following table gives data, from  May 15 till July 6, for the total number of cases, the number of patients who have recovered, and the number of patients under active care.

May 15 has been chosen as the starting date because phase 3 of the lockdown had ended and normal life was just being resumed. It therefore gave the data a fairly uniform base, free of policy change-induced shocks. A comparison of the rates of change in these parameters makes it possible to discern the slowing down of the diseases and, barring, a surge in news cases, broadly map the trajectory of cases.

Of course, a caveat is needed. Two big confounding factors remain testing rates and the government’s denial of community transmission. Recovery rates do increase because that’s the natural course during a pandemic and we won’t discover more new cases unless we test more, which is why leading epidemiologists like Dr Jayaprakash Muliyil think most cases are going under the radar. For this exercise, however, we will take the government’s data at face value.

What the graph tells us

Column 1 shows that although the absolute number of new cases has kept increasing,  the rate of  growth has  slowed from doubling in 14 days till May 29, to 17 days by June 14. It has taken 20 days to double again by July 3-4. This slowdown is welcome, but it is the least reliable (although most quoted) datum for charting the future course of the disease, because it is the one most affected by government interventions.

In India, this is particularly so because a good part of the increase is a product of more intensive – though by no means adequate or even geographically uniform – testing, which has gone up from around 4200 tests per day on March 24, to more than 150,000 today. One consequence of this is the inclusion of a higher proportion of those who are mildly affected by the disease.

Column 2 gives a sense of the number of patients who recover every day. This has been rising much more rapidly than the infection rate throughout the 46 days of the survey, but the rate of recovery too has been slowing down. Recoveries per day doubled in just 9 days by May 24, then doubled again in another 12 days by June 5. This slowed down further after the lockdown was lifted to doubling in 15.5 days ( June20/21). In the last days of June the rate of recovery has slowed down still more, with the doubling rate likely to be 17 days.

Column 3 shows that the higher recovery rate has been mirrored by a slower growth of active cases. Whereas new cases increased by 6.5 times between May 15 and  June 30, active cases increased by only four times. Better still, the doubling rate of active cases has also slowed sharply from 18 days  between May 15 and June 3, to 25 days from June 2 to  June 30.

Columns 4 and 5, plotted in the graph above, give us a sense of the  average rate of improvement in these two parameters per day. It is 0.63% per day in recoveries and 0.54% per day in active cases. A simple linear extrapolation would then suggest the tide turning in September.

While comforting, however, this does not tell the whole story, for all-India, there are more new patients detected with COVID-19 every day than there are patients who have recovered:

The challenge for India is to narrow the gap between the blue and green curves so that eventually daily recoveries outpace daily new infections. That point would mark the peak, though hitting the peak, by itself is no guarantee of the pandemic’s end.  In Europe, China, Malaysia  and several others in Asia, the active disease count fell fairly rapidly after that point as recoveries continue to grow. But then there are also countries which have either plateaued after peaking, or had a resurgence of cases (eg. Iran) thereafter. It is too early to tell which way India will go.

In India, there are three big imponderables. First, the danger of the community transmission we see in large metros spreading to rural areas and smaller cities and  towns. Second, the inadequate amount of testing, particularly in some populous states like Uttar Pradesh and Bihar, gives us an inexact sense of the total disease count. But by far the most disruptive of developments that could derail these predictions is the inability of even the augmented treatment facilities we are putting in place to cope with the sheer number of active cases there will be. By the beginning of September, at the present 25-day doubling rate, active cases will rise to around 1.2 million patients by that date.

Where will so many beds come from? In  2015, Price Waterhouse had estimated that there were 1.3 beds per 1000 population, in India. This amounted to 1.75 million beds, which  was far from sufficient to meet the requirements that arose out of  accidents, diseases, localised epidemics, pregnancies and premature births. Even if  the number of beds has  gone up 50 percent since then, and that all of the increase can be sequestered  for coping with the pandemic, There will still be a shortage of 600,000 beds. The inevitable decline in the quality of treatment that will result from trying to cope, will slow down recovery and increase the number of deaths further.

As the enormity of the problem dawns upon the state governments, the knee-jerk reaction of many of them could be to reimpose lockdowns, or  harden them where they already exist. This must not happen.

Our bitter experience of the past three months has shown that any  lockdown that is not back-stopped by financial sustenance of the kind that was given by the government of  Malaysia, will again fail to contain the disease. But  the harm that it will do to the economy will persist for  years to come. This is because once an airline, a hotel chain, a bank, a mobile telephony company,  an industrial enterprise,  a restaurant or a cinema hall goes bankrupt, debt recovery procedures kick in that make it impossible for it to restart again.  Thus the end of the pandemic will not therefore re-start these enterprises automatically.

Delhi example worth emulating

To save the economy, a phased relaxation of the lockdown is needed. If a COVID-19 calamity is not to be replaced by an economic one, this must start well before the new lockdown period ends.

Sacks of unsold vegetables in the mandi, that are slowly starting to rot in the harsh sun. Credit: The Wire.

The happy consensus between the prime minister and all chief ministers that the national lockdown needs to be extended for another two weeks cannot hide the fact that when Narendra Modi ordered the shutting down of all ‘non-essential’ activity on March 24, neither he nor his  advisers had thought through what the consequences would be – and when and how it could be lifted.

In the past couple of days, it has become obvious that the state governments, with one or two notable exceptions, have no idea either.

China had done a lockdown in Hubei province, and succeeded in containing  the virus.  Five other countries – France, Italy, New Zealand, Poland, and the UK – had, or were about to declare a similar lockdown. Modi’s India had to be among the first.

It is clear that, so far as the economy is concerned, no decision-maker in India has the faintest idea of what to do next. In the first days of the lockdown this was excusable: the tacit assumption was that the number of new cases would start to come down after two weeks of its imposition, as had happened in Hubei. The government would therefore be able to lift its punishing restrictions when there were no more new cases

Instead, the opposite happened, and the number of active cases  ballooned from 519 on March 24 to 7,367  on April 12. The lack of a contingency plan – in fact of any plan whatever – became apparent when millions of migrant workers who had been thrown out of work and dwelling began a desperate march home to villages hundreds of kilometres away with the little money they had saved and what their employers had given them. Had it not been for the prompt action of the state governments, and the kindness of people on the roads, this could have turned into a major humanitarian disaster.

The happy consensus between the prime minister and all chief ministers that the national lockdown needs to be extended for another two weeks cannot hide the fact that when Narendra Modi ordered the shutting down of all ‘non-essential’ activity on March 24, neither he nor his  advisers had thought through what the consequences would be – and when and how it could be lifted.

In the past couple of days, it has become obvious that the state governments, with one or two notable exceptions, have no idea either.

China had done a lockdown in Hubei province, and succeeded in containing  the virus.  Five other countries – France, Italy, New Zealand, Poland, and the UK – had, or were about to declare a similar lockdown. Modi’s India had to be among the first.

It is clear that, so far as the economy is concerned, no decision-maker in India has the faintest idea of what to do next. In the first days of the lockdown this was excusable: the tacit assumption was that the number of new cases would start to come down after two weeks of its imposition, as had happened in Hubei. The government would therefore be able to lift its punishing restrictions when there were no more new cases

Instead, the opposite happened, and the number of active cases  ballooned from 519 on March 24 to 7,367  on April 12. The lack of a contingency plan – in fact of any plan whatever – became apparent when millions of migrant workers who had been thrown out of work and dwelling began a desperate march home to villages hundreds of kilometres away with the little money they had saved and what their employers had given them. Had it not been for the prompt action of the state governments, and the kindness of people on the roads, this could have turned into a major humanitarian disaster.

However, as some studies from Singapore have confirmed, central air-conditioning in buildings may pose risks,. Could the ubiquity of air-conditioning in Singapore and the Gulf countries like Bahrain, Qatar and Kuwait, therefore account for their much higher infection rates than India? Or the fact that they have higher ‘expat’ populations that may have been exposed to the virus in their home countries?

Either way, with the summer upon us, it may be necessary to keep centrally air conditioned establishments and offices locked down and limit travel in air conditioned trains and buses – whose filters are not as efficient as those on modern aircraft – till no more new cases have been reported for some time. The travails of the well to do  are not therefore going to end soon. But that does not mean the poor have to suffer with them.

To save the economy, a phased relaxation of the lockdown is needed. If a COVID-19 calamity is not to be replaced by an economic one, this must start well before the new lockdown period ends.

By springing the lockdown on millions of migrant workers, the Modi government has once again shown a combination of unseemly haste and organisational ineptitude.

Migrant workers wait to board a bus to their respective villages during the national lockdown, at Kaushambi, Ghaziabad, March 29, 2020. Photo: PTI/Ravi Choudhary

With every hour that passes, the fate of India’s poor is being sealed more and more firmly. That fate is to confront possible death at the hands of COVID-19. As I had feared, employers have responded to the sudden and country-wide lockdown and the consequent total cut-off of their cash flow by firing their workers. And the workers are heading “home”.

When they reach their homes in the villages and small towns, these will turn it into death traps.

An NDTV news report from two days ago showing migrants thrown out of work at Unnao in Uttar Oradesh walking 90 km ‘home’ to Barabanki was greeted by a storm of unimaginably obscene abuse by self-appointed Modi bhakts, who berated the channel for trying to use a national emergency to defame their hallowed leader.

But within 24 hours of that venomous outburst, district magistrates in every metropolis of the country were scrambling to find buses to take migrant workers ‘home’.

That ‘home’, the village, could become a death trap. Even as I write, the number of confirmed COVID-19 cases in India has jumped from 834 to 980. At least four times as many people have had the disease but are likely to recover by themselves. There are thus at least 4,000 others out there spreading the disease without knowing it even as I write.

The lockout is only in its fifth day, so each of them will have been in contact with a large number of persons even before it began. What is more, among the poor, it has only reduced, and cannot eliminate, close social contact. So there are ten more days in which anyone who is infected, whether he or she knows it or not, can infect other people.

In the 14 days between getting infected and overcoming the virus, each of them will have been in close proximity with scores of persons. So we are virtually certain to see a rapid spread of the disease in the coming days.

How fast can it be? We now have one concrete measure of the speed with which the virus can spread when the migrants get home: A Sikh priest who returned to India after two weeks in Italy and Germany on March 6 broke quarantine and visited Anandpur Sahib and 15 villages before he died on March 18. He is believed to have infected 23 persons, including 14 from his own family, before he died.

Health workers spray disinfectant in Chikmaglur, March 28, 2020. Photo: PTI

But this has to be a gross underestimate because 80% of those who get infected recover on their own. However while they are doing so, they too are carriers of the virus. Thus, that one Sikh priest must have infected more than a hundred persons.

This gives us an idea of what the approaching pandemic will look like if the outflow of migrant workers is not stopped within the next day or two. At this hundred to one ratio, if only ten out of India’s 139 million migrant workers travel home in the coming days and even one in a thousand of them is carrying the virus when he boards the bus, ten thousand carriers of the virus will have fanned out into the villages within the next fortnight. There the multiplier is likely to be far smaller, but even so, we are already staring a pandemic that can infect millions in the face.

All this could easily have been anticipated and forestalled, for the Sikh priest died six full days before Prime Minister Narendra Modi announced his total lockdown of India. The size of India’s unorganised sector and its component of migrant workers is well known, and the ruthlessness of their employers is also well known. And any good undergraduate student of growth economics could have told it that a total lockdown of the country would mean instant unemployment for hundreds of millions of workers.

It is therefore difficult not to conclude that the Modi government has once again shown a combination of unseemly haste and organisational ineptitude, which made such a mess of demonetisation and the introduction of the Goods and Services Tax during its first term in office.

This is not, however, the time for finger pointing. Seven actions can still minimise the spread of the disease to the rural areas. These are:

1. Immediately ban the laying-off of workers in all sectors of the economy and make it a punishable offence.

2. Meet the fixed costs of all working establishments – airlines, bus companies, manufacturing companies and wholesale and retail stores of all sizes, on condition that they do not lay off, and especially, not send away migrant workers.

3. Meet 50% of the wage bill of all non-migrant workers. If they are provided accommodation quarantine them there.

4. Base compensation on documentary proof of the finances of the enterprises and make it strictly conditional upon their following these rules. Breaking them will not only mean cessation of aid and recovery proceedings being taken, but also imprisonment for the employer.

5. Make it a criminal offence to throw anyone out of a rented accommodation during and immediately and for at least a month after the lockout period.

6. Then seal off all the major cities from the countryside. This is the most effective way surest way to virus must not be allowed to get to the villages.