As I sat to have breakfast two Sundays ago at my home in Delhi, I knew immediately that something was wrong. I couldn’t taste the food at all. Quietly, I pulled away from the table where my wife and 18-month-old son were also eating. Only a few days prior, the Indian Council of Medical Research (ICMR) had added the loss of taste and smell as symptoms of Covid-19. I withdrew into our study and pulled up recent literature. A research paper from France suggested that this particular symptom has a specificity of 95 per cent for the disease, which means most of the people who get the symptom have the disease and only 5 per cent are wrongly diagnosed.
Admittedly, this sequence of events appears rather dramatic. Who abandons a meal to look into scientific journals? Ordinarily, I wouldn’t either. But I had been following Covid-19 more than just out of personal concern — it was also work. I work as a strategy adviser to a number of global health programmes.
I began by analysing the situation as if it was work: Look at the data and decide the course of action. But soon enough, more primal emotions made their presence felt. This was, after all, not public health; this was my health. I caught myself thinking that the French were perhaps too different from us for that study to be relevant. Classic signs of denial. But the realist in me couldn’t see past ‘95 per cent’. After a few minutes, I was convinced I had been infected by the coronavirus.
India’s low testing rate
Many questions came to mind. Whom might I have infected? How did I get infected despite being the paranoid one in the family, never once stepping out unnecessarily or without a mask? Fear became the dominant emotion. Fear for my parents next door who are on either side of 70. For my sister and her kids who were staying with them. For my son and for my wife. Whether I got it from my family or I gave it to them didn’t matter – what mattered was that my family might have been infected.
I immediately isolated myself. When I suggested that the entire family get tested, there was resistance. I could only persuade them to wear masks at my parents’ house. In case, one of them had it, the others were at risk. I resigned to getting myself tested first. I frantically called four different private labs. Finally, I got a call back from one of them. Some of the other labs didn’t call back until three days later. It’s a matter of privilege and some luck that I got tested at home within 24 hours of experiencing a symptom. In another 24 hours, I was declared positive.
Even before it had become personal, I was disappointed with India’s low testing rates. There were only 110 tests per day per million population (on 16 June, around the time of my infection). Even with recently ramped up numbers, these were among the lowest among the 10 worst-affected countries. On 16 June, India conducted 1,50,000 tests, far below our estimated test capacity of 5,00,000 per day.
All these numbers were grave, but I only grasped the full utility of testing when I tested positive. It is obvious that adequate testing brings full visibility of the problem to governments. It is invaluable for individuals as well: timely testing is actionable data. At least three actions resulted from my test: 1) I could get my family tested as per guidelines; 2) It was the relevant ammunition to tell my parents and sister to split up into smaller households. If you are part of an Indian family, you would know that such decisions are not easy; 3) I could inform all those I had come in contact with about my status.
Perhaps, for the first time in my life, I became a customer of the public health system.
Execution — a mixed bag
Middle-class privilege keeps interactions with the public health system to a minimum, an unfortunate situation that must change. My experience has been a mixed bag. Quite often, I was very impressed at the efforts of both the Aam Aadmi Party government in Delhi and the Narendra Modi government. For one, both governments called me even before my Covid results were communicated by the lab. Over the next few days, I routinely received calls from healthcare professionals on behalf of the Delhi government. The first call from a doctor was exemplary – she patiently guided me through what I needed to do during my home isolation. Some of the calls were automated – one had to punch in 1 or 2 depending on how one was feeling. A range of persuasion tactics was used to ensure compliance with home isolation. One message that I received after missing an automated call was particularly threatening: “To avoid getting transferred to Covid care centres, please attend the calls regularly.”
Of course, there were issues in the execution. Without getting into the merit of the policy, no Covid-positive sticker was plastered outside our flat. I had provided my correct address in the ICMR form and to the lab, but for some reason, the address on my Aadhaar card was used. I pointed this to at least 10 callers, but the address was never updated. Unfortunately, this meant frontline workers at the other end of the city were tasked to visit me. If any contact tracing was done in my case, I am not aware of it. Further, it took 3-4 days to get my family tested. Centre-state dynamic also kept matters interesting. An order by the centrally appointed Lieutenant Governor Anil Baijal questionably suggested that the disease was spreading in Delhi because the home quarantined patients were not following orders and should be transferred to institutional quarantine facilities. When there was an outcry by the Delhi government that this would only discourage people from getting tested, the order was withdrawn.
As a ‘customer’, I can provide some (unsolicited) feedback to the AAP and BJP governments. We need to dramatically ramp up testing and reduce delays in high-load areas. Governments may want to consider subsidising private testing to increase reach. In all decision-making meetings, governments must include experts in public health and human behaviour. We shouldn’t be making any decision that would drive people to hide the disease or public officials to bury numbers. Many have already pointed out that government should not treat Covid-19 as a law and order problem – members of the community should be treated as partners in surveillance efforts.
We should measure the right data even if they don’t make us look good – a recent emphasis on percentage of recovered cases is a case in point. That number doesn’t tell us anything meaningful. It will only trend up with time and eventually, once the pandemic is over, we will have 96-97 per cent recovered cases (the remaining being fatalities). With infectious diseases, details matter. Incorrect addresses and slow-moving information can impair efforts in tackling a fast-moving disease. Every identified case is an opportunity to identify more cases – it is inexcusable if contact tracing is missed even in a single case. The ICMR form, which is being filled by everyone who gets a test, should have an optional online interface. This would help the coordinating authorities build a real-time picture of testing and associated gaps. Crucially, we need to ensure that the 20 per cent of cases that require hospitalisation get adequate care. Too many nightmarish stories are coming out in the public domain to be ignored.
Despite the dramatic growth in cases, we have a number of things going for us: a younger population, strong indigenous production capability for medicines/tests, and many of the right frontline structures. Dharavi’s remarkable turnaround shows what good systems, localised strategies, and ruthless implementation can do even in extremely challenging settings. As a country, we will turn the corner as long as we are responsive to data from the ground and raise our implementation efforts dramatically.
The author is Partner at Alstonia Impact, a development advisory firm based in New Delhi. He has advised organisations such as the Bill & Melinda Gates Foundation and the World Bank. Views are personal.
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