Between extending lockdown and lifting it, India must walk the middle path

The lockdown has worked. But an overdose of it could kill through long-lasting side-effects. It should be systematically loosened or de-escalated

It’s unlikely that Jair Bolsonaro knew how well-timed his letter to Narendra Modi was when he used the Ramayana legend of Lord Hanuman bringing the Sanjivani Booti to save Lakshman’s life, while seeking hydroxychloroquine and paracetamol from India.

It will be something if his staff has such a pucca Hanuman bhakt that he would also ensure the letter would arrive pretty much coinciding with Hanuman Jayanti earlier this week.

Nevertheless, it makes us reflect on the same lore as we assess the prospects of the three-week lockdown being extended (we hope not), fully lifted (we pray not), or systematically loosened or de-escalated. That third option we prefer and we are arguing why. With a little help, of course, from Bajrangbali. Our Gods after all, aren’t just benevolent. They are also forgiving, and have a sense of humour. Especially the one Bolsonaro invoked.

Go back to that legend of Hanuman, with Lakshman lying unconscious, struck by Ravan’s warrior son Meghnad (also known as Indrajit) with what might be the equivalent of a smart, guided weapon today. Lanka’s finest doctor Sushen said only a magical herb from the Himalayas, Sanjivani Booti (life-giving herb), could save him. And Jambwant, the bear-king, said only Hanuman had the strength to go get it.

illustration by Binay Sinha

 

We know what happened next. Unable to identify the herb, Hanuman brought the entire Dronagiri mountain. That’s the most familiar and popular picture in the Hanuman iconography. And no worries, as Sushen picked the herb in a jiffy.

Now, see how this applies to our current situation. The ICMR started monitoring the rise of coronavirus infections in India in mid-February. Initially, only symptomatic suspects, foreign returnees or their contacts were tested — a very small number. In fact, on the basis of tests per million, the smallest for any significant country in the world. The experts at the ICMR leaned on an old, tried, tested and robust method in Indian epidemiology, a sentinel surveillance.

This entailed picking up a sample of patients with SARI (Severe Acute Respiratory Infection), or severe pneumonia in the ICUs of about 50 major hospitals. The first 826 samples in two weeks showed up no Covid-19 infection. It was seen as evidence that the disease was still more or less in stage one (imported) and partly in two (local contact infection).

In the following few days, however, as more tests took place, by March 19, two positive cases emerged. These were just two in 965, but the first two. Nobody has told me this, but I am guessing, having known and covered the system closely in the past, that this was an alarm bell. The same day, sampling was extended to all SARI patients in hospitals across the country. Therefore, while only 965 were tested in the first five weeks, another 4,946 were tested in the next two, until April 2.

This has now been reported in an important ICMR study published Thursday in the Indian Journal of Medical Research (IJMR), showing 104 coronavirus-positives out of 5,911 SARI patients. It is still only 1.8 per cent. But it isn’t negligible. These indications, we can safely presume, were becoming evident by March 21-23. This explains the timing, urgency and the weight of the lockdown.

This was no time for searching for a precise, targeted solution. In short, this wasn’t the time to identify the herb, but to haul the mountain. That done, can you then sit in front of the mountain and hope for the best another three weeks after that?

You could, but then you risk Lakshman, which is the economy and also the struggling poorest of India, dying in the meantime. You need that somebody wise now to find that one herb, or a bunch of herbs to move forward.

Much global assessment has emerged, listing India’s lockdown as the severest response to the pandemic. Most notable is a graphic used by The Economist based on the Stringency Index developed by the Blavatnik School of Government at the University of Oxford. India tops this, at 100 per cent, with even Italy at 90. But the same index also shows us our limitations. On fiscal stimulus as a percentage of GDP, India is the lowest on these charts.

It is not inexplicable. Of all the countries listed and ranked here, India is the poorest. The next ‘poorest’ aren’t quite poor, with both China and Malaysia at about five times India’s per capita GDP. India, therefore, had a triple challenge. It is crowded, has a crumbling health system, and is poor. Given this situation, a drastic lockdown was called for.

The results show that it has worked. The number of fresh infections is going up, especially with expanding testing. But the graph isn’t rising even geometrically, forget exponentially.

Something has worked. And whatever be the other theories, from BCG vaccines to chloroquine in our blood or guesswork genetics, this lockdown has been the biggest contributor. The instinctive call would then be to simply extend it. Many state governments have already demanded this. A couple have already extended it till the end of the month on their own.

Is it sustainable? Or is it like an overdose of a medicine that saves your life in the short run but kills you through long-lasting side-effects?

There were pointers in the excellent “Containment Plan” made public by the Union Ministry of Health earlier this week. Looking at it closely, you might think that the magic “herb” was Rajasthan’s Bhilwara Model, but spread over much larger geographies and customised for different local and regional conditions and realities.

This could see, instead of the entire country remaining — and frankly throttling itself — in suspended animation, waking up carefully while a number of Bhilwaras are identified and Lakshman Rekhas drawn around them. We have seen some of that already with the declaration of “hotspots” and “containment zones” in some states, including Delhi.

That is the model to go for. It is enormously more cumbersome than a simple, total lockdown with one whistle. But taken beyond three weeks, it will be counter-productive. Too many Indians live on daily wages, from meal-to-meal. The Rabi crop is waiting for harvest and storage, fields have to be readied for Kharif. Factories — even the globally vaunted pharma units — have to resume working. And wherever there’s a threat, you have this fine containment model.

The idea of buying more ventilators is much in fashion as there is a paucity. But cruel as it is, we need to understand what life on a ventilator means. At his usual White House press briefing earlier this week, Donald Trump answered the clamour for more ventilators by asking, ominously, do you want me to tell you how many people who go on the ventilator survive? You wouldn’t want to know.

But, a day earlier, New York Governor Andrew Cuomo had let that answer slip in a weak moment. Just about 20 per cent, he said. So, the best thing is to save the patient before he goes on the ventilator.

Here, we have put the entire nation of 1.38 billion, a $3-trillion economy on the ventilator. The time to think of letting the patient breathe, at least partly, on her own, is now.

By Special Arrangement with ThePrint