Stepping up the Vigil
Unlock 1.0 could be grim for Tamil Nadu, a state that witnessed a near ten-fold jump in Covid cases last month, from 2,323 in April to 22,333 on May 31. With 145 deaths reported through May, even the mortality rate surged to five times that of the earlier period. The only consolation perhaps is that at 0.7 per cent, Tamil Nadu’s mortality rate is well below the national average of 2.8 per cent and of other large states such as Maharashtra and Gujarat.
The worry now is the continuing spread of Covid in northern Chennai and its contiguous districts, which are densely populated and house much of the state’s industries. More than half the ‘active’ Covid cases are in Chennai, which also accounts for maximum deaths, and the Greater Chennai Corporation zones of Royapuram, Kodambakkam and Thiru. Vi Ka Nagar and Teynampet are among the hotspots within Chennai. With a sharp rise in cases over the past few days, the doubling rate is now less than a week. The national average is about 14 days.
The state government has been proactive against Covid. On March 15, Chief Minister E.K. Palaniswami appointed a Covid task force headed by chief secretary K. Shanmugam. On May 1, J. Radhakrishnan, a senior IAS officer and principal secretary (revenue administration, disaster management and mitigation), was made the special nodal officer for the Greater Chennai Corporation and tasked with checking the outbreak in Chennai, particularly its northern parts. Armed with a micro plan, a 500-member team, including 120 sanitary inspectors, began door to door screening and testing. Those testing positive were quarantined or put under hospital care. To build immunity, each household was provided a medical kit, including herbal drink powder, zinc tablets and multi-vitamins, along with masks and sanitisers.
It is the densely populated areas that have reported the most cases in Chennai. Experts are now calling for focused testing of symptomatic people and the vulnerable segments, such as senior citizens. By May 31, 2,052 senior citizens and 1,286 children under the age of 12 were afflicted by Covid. A committee constituted to set guidelines for the management of senior citizens and individuals with co-morbid conditions has made several recommendations, disease registry, intensive treatment, monitoring and follow-up on Covid patients through virtual groups, specific diets for patients and integration of Indian medicine into the treatment plan.
Palaniswami is banking heavily on aggressive testing and intensive care to keep the death rate low. Legislative assembly elections are less than a year away and the ruling AIADMK will be judged by the government’s performance during the pandemic. Convinced that stringent enforcement of the lockdown was the most effective weapon, Palaniswami had, on April 24, come up with a ‘double lockdown’ plan, a lockdown within the lockdown, with no one to be seen outside their homes, till May 3 for Chennai, Coimbatore, Madurai, Salem and Tiruppur. Only when officials pointed out that April 30 was pay day and the next three days were government holidays did he curtail it to four days (April 26-29).
So far, the administration has come down hard on lockdown violations. As of June 2, the Tamil Nadu police had arrested 573,849 violators, seized 443,094 vehicles from those who stepped out for non-essential purposes and collected Rs 9.76 crore in fines from them. Palaniswami has asked senior bureaucrats to pursue a holistic strategy that will check the spread of the virus and help the state recover from the economic impact of the lockdown. Beginning May 23, all government offices have switched to a six-day week, for the first time in decades. The chief minister has ordered the free supply of cloth masks to 2.6 million slum-dwellers. This will now be extended to all 20 million ration card-holding families through June.
More forces at the front line
To augment the medical workforce, the government recruited 530 doctors, 1,000 nurses and 1,508 lab technicians over the past few months. Additionally, the state Medical Services Corporation selected 1,323 nurses, who were given postings immediately. Another 2,570 nurses were appointed for six months, beginning May 8, while the services of doctors, nurses and lab technicians due to retire this March and April were extended by two months. Palaniswami also announced that front line medical staff afflicted by COVID-19 will be entitled to a cash grant of Rs 2 lakh and free treatment. In case of death, their families will be paid Rs 50 lakh and one member will get a government job.
Officials attribute the surge in Covid cases to intensive testing. About 500,000 tests have been conducted so far. While the first batch of 100,000 RT-PCR (Reverse Transcription Polymerase Chain Reaction) test kits arrived from South Korea on May 17, another 900,000 kits are coming in at the rate of 100,000 a week. “The state’s low death rate is because of early diagnosis and treatment. Aggressive testing with maximum number of samples has been the highlight of our strategy,” says health minister Dr C. Vijaya Baskar. “The mortality rate will increase when more people over the age of 60 are affected. That’s why it is important to protect the older people.” Public health experts fear that whenever schools reopen, children could become the biggest carriers of the virus to their grandparents. The death audit committee set up in April has observed the death rate to be higher in the 50-plus age group whereas there have been no deaths among children below the age of 12.
Lifting the barriers
With Covid cases concentrated in specific areas, the number of containment zones has dropped sharply to less than half, from 635 on May 22 to 254 on May 29 in Chennai and 1,143 to 568 the same week across the state. As of May 29, the containment zones were restricted to 21 of the state’s 37 districts. A week ago, these were spread across 30 districts. “Containment serves no purpose anymore as the magnitude of the spread is so large. Moreover, there is no denial of community transmission happening in Chennai. Preventing deaths is the biggest challenge now,” says Dr Jayaprakash Muliyil, chairman, Scientific Advisory Committee, National Institute of Epidemiology, Chennai.
With the easing of the lockdown, the state is resuming regular hospital services, including elective surgeries. The government is encouraging private hospitals and the Indian Medical Association’s fever clinics to step up services. While many areas may no longer be classified as containment clusters, Covid continues to remain a challenge in the near future. As veteran virologist Dr T. Jacob John says: “As long as there are people, the virus will find them.”
Palaniswami’s other big test will be to revive the economy ahead of the polls next year. His government has set up a committee, chaired by former RBI governor C. Rangarajan, to formulate short- and medium-term economic strategies. A report is expected in August.
Intensive care: At the LNJ P Hospital, Delhi’s largest Covid care facility
Kejriwal, however, insists there is no need for panic. “I want to assure the people that if anyone from your family gets infected, we will take care. We have enough beds,” he said on June 1. The Delhi government has launched a mobile app to help track the number of Covid beds available in hospitals. On April 7, amid criticism from the opposition, Kejriwal had promised to scale up the number of beds from 3,000 to 30,000, by tapping hotels, banquet halls and guesthouses. On May 25, though, the chief minister said the city’s government and private hospitals together had some 4,500 beds.
According to the state’s health department, as on June 3, there were 8,386 beds, of which 3,440 were occupied. To deal with the spike in cases, the state government has recommended home treatment for the mildly symptomatic patients and issued guidelines for the same. Meanwhile, more hospitals are being declared Covid-dedicated and all 117 private hospitals have been asked to reserve 20 per cent beds for Covid patients. “We will have 9,500 beds by June 5,” claims Kejriwal.
Delhi reported its first COVID-19 case on March 2. Two days later, Kejriwal set up a special task force to monitor the pandemic. His government has kept its promise to significantly ramp up testing, as of May 31, the figure stood at 10,537 samples per million people.
Too much too soon?
The string of relaxations announced after May 31 include the reopening of salons and barber shops, lifting the two-passenger limit for car travel and the odd-even system for shops. Many experts view the decisions as an open invitation to more infections. “The guidelines for preventing large congregations must be clear, strict and binding. The next course of infection spread occurs mostly through clusters. Among them, clusters that mix the elderly and other vulnerable sections with the healthy are more dangerous,” says Dr Giridhar R. Babu, head of life course epidemiology, Public Health Foundation of India.
Others caution against the government’s move to home-quarantine the not so serious Covid patients. “The government must consider various factors, such as the patient’s age, living space, number of family members, and the health status of the individual and the entire family. Those who tick all the boxes can be kept in home isolation with daily virtual monitoring,” says Dr Atul Kakar, senior consultant (medicine) at Delhi’s Sir Ganga Ram Hospital.
How the Kejriwal government manages the city’s containment zones, where an estimated 500,000 people live, will be a key determinant in the control of Covid. The government’s strategy is to unlock these areas if they do not report any new cases. While several clusters have been opened up, some like Jahagirpuri, Jhilmil Colony and Nizamuddin Basti have remained closed since March. Nizamuddin is where a big congregation by the Tablighi Jamaat in March became one of the early sources of transmission of Covid in the country.
Protecting the capital’s front line healthcare workers remains a daunting task. One in every 30 Covid patients in Delhi is a healthcare worker. “Healthcare workers face repeated exposure to asymptomatic patients. Shortage of PPE and lack of public awareness lead to infections,” says Dr Harjit Bhatti, president, Progressive Medicos and Scientists Forum, an organisation of medical professionals of the All India Institute of Medical Sciences, Delhi.
With the number of cases rising, the Delhi government, on June 1, directed all 11 district magistrates to increase bed capacity by identifying banquet halls and indoor stadiums. They were also asked to identify additional cremation/ burial grounds on “top priority”. Kejriwal has said that experts told him that the Covid curve in Delhi will start flattening in July-end or early August. Health minister Satyendar Jain says the government is preparing at least a month in advance as the Covid problem may not end anytime soon.
There is also a revenue crunch to deal with. Deputy Chief Minister Manish Sisodia said Delhi has sought immediate assistance of Rs 5,000 crore from the Centre. “We need around Rs 3,500 crore every month just to pay salaries and bear office expenses,” said Sisodia, who has written to Union finance minister Nirmala Sitharaman for assistance.
Fix the Fault Line
The departed: A Covid victim’s body being taken for last rites in Ahmedabad
Stung, Gujarat’s health minister Nitin Patel said he had worked unstintingly “though my age is 64 and being a senior citizen, I am advised not to venture out of home”. He also said the morale of corona warriors should not be affected by overly harsh criticism. A week or so later, another Gujarat HC bench echoed the health minister’s concerns, noting that in “times of crisis, we need to bind, not bicker. The COVID-19 crisis is a humanitarian crisis, not a political crisis. Hence, it is imperative that no one politicise this issue”. Had it not been for the government, the court now suggested, “by now, we all would have been dead”. It also warned commentators, on social media particularly, to not take the court’s many orders criticising the state government for its COVID-19 response out of context.
If the state’s BJP government is keen for its critics to not cast aspersions or place blame, its own functionaries place the blame for Ahmedabad’s situation squarely on the city’s Muslim population living in the walled city, more specifically those Muslims returning from the now notorious Tablighi Jamaat conference in New Delhi in March. Other states may have coped with returning conference-goers, with the Uttar Pradesh government, for instance, telling the state’s high court that it was no longer holding any Jamaat returnees in quarantine centres, but Ahmedabad authorities claim its minorities have been uniquely recalcitrant.
A Gujarat government official, requesting anonymity, said, “We had a good strategy in place to tackle minority community members in Surat and Vadodara, but we paid a heavy price in Ahmedabad as the minority community did not comply and tried to hide incidences of coronavirus infections and resisted the government’s attempts to screen residents.”
Though accurate numbers are hard to come by, most reported estimates claim Muslims, who make up less than 15 per cent of Ahmedabad’s population, account for over 60 per cent of the city’s Covid infections.
To contain the spread, government agencies reached out to Muslims with the help of politicians and local leaders of the community. For instance, Congress MLAs Imran Khedawala and Gyasuddin Shaikh worked with the Ahmedabad Municipal Corporation and health officials to convince Muslims to get tested and adhere to the Covid containment protocols. “All of us rose to the occasion to fight what is a battle to save humanity,” says Khedawala.
The authorities, though, had to grapple with tensions arising out of trust deficit, such as an incident of stone-pelting last month involving Muslims residing in the containment areas and the police. The near-riot situation was broken up only after the police resorted to firing tear gas and lathi-charge.
A government-affiliated medical expert, who again requested anonymity, said, “An iron hand was required to deal with Jamaatis and the Muslim population in the walled city.” The expert would not be drawn on the responsibility of, for instance, the Civil Hospital in Ahmedabad, in which 415 of the 789 deaths were recorded by May 31; according to the Gujarat government, nearly 83 per cent of the victims at the hospital had “severe comorbidities”.
In the fifth phase of the lockdown that began on June 1, Ahmedabad has decided to concentrate its efforts on people in the 46 so-called micro-containment zones. But its public relations will surely have to improve. Salim Mohammed, a 32-year-old resident of the walled city, recalls how his father and brother helped distribute rations in the first week of April, when the entire country was in lockdown. They feared they had been exposed to the virus, but could not persuade the local government hospital to test them, because they were yet to show symptoms. Four days later, Salim’s 59-year-old grandfather developed symptoms and tested positive; he died in nine days. Salim’s father also tested positive, as he had long suspected. “We live in cramped quarters; for years, Muslim areas have been underdeveloped. They are hotbeds of contamination,” he says. It didn’t help, Salim adds, “that Muslims were treated as suspects, were being segregated into different wards, as though we had brought the infection to the city.”
Gujarat needs to re-focus on improving its number of daily tests to avoid undetected or missing cases, something that has already cost it dearly. On May 15, the rate of positive cases among those tested was 8.8 per cent, as against 2.6 per cent a month ago. This means that within a month, about nine out of 100 people were testing positive as opposed to two, indicating that cases had been missed in April, when testing numbers had been low. Perhaps if the state had reached out extensively and tested consistently, the virus would have been contained more effectively.
WITH INPUTS FROM SONALI ACHARJEE