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Friday, May 27, 2022

What has really tripped up India’s Covid efforts?

An outdated administrative system and a knowledge elite who have soaked up prestige but not delivered the facts are the biggest hurdle between us and a material society with a modern accountable state.

Written by Milind Sohoni , Alakhya Deshmukh |
Updated: May 3, 2021 8:55:33 am
As late as August 18, 2020, when the first wave was in full swing, the Supreme Court accepted the statement of the Solicitor General of India that no special plan was required.(Illustration by C R Sasikumar)

The COVID-19 epidemic has come back with a vengeance. As per official data, we now have over three lakh cases and 3,000 deaths every day. In most cities across India there is great demand for ICUs and critical care beds, a shortage of oxygen and hoarding of key medicines. Other shortages may emerge as the days go by.

Our top scientists and bureaucrats have claimed that the second wave was indeed expected and we were prepared. But the planning was confounded by two factors: First, a more infectious mutation of the virus, and second, the people, for being “arrogant” and not following COVID discipline. Our media wants to pin the blame on politicians for their rallies, the Kumbh and for not working together. But we argue that this is a routine failure of our centralised scientific and administrative bureaucracy common to other areas of development.

We often compare ourselves with Europe or the US. A visit to the webpage of the Centre for Disease Control (CDC), US gives us several important facts, state-wise, about the epidemic there, diligently collected by many university researchers. For example, we learn that the current hospitalisation demand is about 15 per 100,000 population and the mortality is 6 per cent and dropping. The median hospital stay is five days for a non-ICU patient and 14 days for an ICU-patient.

None of these clinical facts are known for India. And yet, they are crucial for managing the epidemic. As an example, let us analyse what happened in Maharashtra between March 30 and April 20, 2021, close to the current peak.

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COVID-19 care in Maharashtra is broadly organised as tier I consisting of large private hospitals, and well-equipped public hospitals in main cities, tier II of smaller private and public hospitals dotted across the state, and tier III of community or home care. This roughly matches the hierarchy given by the central ministry. Critical care is provided by tier I hospitals, and to some extent, tier II hospitals.

Let us now relate mortality with the availability of critical care beds for severe patients. Inspired by the CDC of the US, let us use indicative values for key parameters and compute a Quality-of-Care Multiplier (table 1). This tells us that we should expect roughly one death per day from a 250-bed tier I critical care hospital, but three deaths from a 250-bed tier II hospital. Tier III is essentially a denial of service for a severe COVID patient.

For any hospital, computing the basic quality-of-care multiplier, that is, recording the mortality and duration of care is basic statistics. In fact, this, along with the number of beds in each tier, defines the preparedness of the district or the city. For example, Nanded’s official preparedness on April 20 was 1,939 tier I beds and 1,156 tier II beds. To its credit, Maharashtra has been both transparent about preparedness and responsive to rising demand.

Given the daily death rate (DDR), it is now easy to estimate hospital utilisation and classify the stress level in a district. We label it as white (0), if all patients get tier I care, grey (1) if some have transitioned into tier II with a higher mortality, and finally black (2) if it has dropped into tier III, effectively a denial of service. Table 2 displays these results for a few districts of Maharashtra as on March 30 and on April 20, 2021. The DDR is computed as a 7-day average.

We see that districts degraded from white (0), to grey (1) and finally to black (2). Maharashtra did increase tier I capacity by 18 per cent and tier II by 24 per cent, but the epidemic was faster. Though Pune and Mumbai saw more deaths, they were also better off. Rural districts of Parbhani and Ahmednagar continue to be poorly provisioned. Severe patients from here must either migrate to neighbouring white (0) and grey (1) districts or retreat into home care. Moreover, as tier I capacity is exhausted, anxiety rises as only poorer quality tier II hospitals are available. The supply chains of these hospitals are weak leading to shortages of oxygen and drugs. Hoarding of services becomes endemic and mortality rises. This chain of events has been reported in many districts of Maharashtra.

Thus, key parameters and a planning approach do reveal the geography of the epidemic and help predict shortages. And yet, our scientific agencies have not come up with any quantitative norm for preparedness or guidelines for states to follow, let alone more sophisticated lifesaving services such as bed allocations or ambulance dispatch software.

Let us come to oxygen availability. Assuming a critical care consumption of 15 kg per patient per day, the current India-wide demand of 4,000 MT indicates that about 2,60,000 patients are under critical care. Assuming tier II care, this gives us about 3,000 deaths every day coming just from these hospitals. This amounts to two deaths per million per day, a number routinely seen across the world and even many parts of India in the first wave. In fact, a peak rate of five deaths per million per day should have been adopted as a planning objective in our National Disaster Management Plan. That would have quickly revealed that the national capacity of 7,000 MT was not adequate and urgent measures were required.

But there may well be no such National Plan for the epidemic. As late as August 18, 2020, when the first wave was in full swing, the Supreme Court accepted the statement of the Solicitor General of India that no special plan was required. It is only now that it has asked the Centre for a national plan on oxygen and vaccinations and the states for an affidavit stating their health infrastructure. Hopefully, these will have the required granularity.

Thus, what we see is the usual problem of poor design of empirical and scientific systems, excessive centralisation and a failure of execution. Fixing this is the job of our sarkari scientists and bureaucrats — an elite salaried class which our politicians did not hire and cannot fire.

Compounding this is the absence of research. Do micro-containment zones work? How does Kerala manage to keep its death rate so low? Is mass-testing of non-symptomatic people a good idea? And broader questions: Are our railway coaches any safer today? Or our classrooms? These should have been answered over the last one year. We have over 3,000 eminent scientists and professors in our elite institutions, with the best students at their disposal. But they have yet to step out of their campus to work, suo moto, on live problems and provide answers. Unless they do this, they will serve neither science nor society.

Thus, it is unfair to blame our people for their anxieties or solely our politicians for their folly. The real problem all along has been an outdated administrative system, and a knowledge elite who have soaked up prestige, but not delivered the facts. They are the biggest hurdle between us and a material society with a modern accountable state.

This article first appeared in the print edition on May 3, 2021 under the title ‘Virus in the system’. Sohoni teaches at IIT Bombay and Deshmukh is a freelance researcher

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