Was India saved by staying below the critical travel threshold and was lockdown and travel restriction the most important public health intervention?
aa r X i v : . [ phy s i c s . s o c - ph ] F e b Was India saved by staying below the critical travel threshold and was lockdown andtravel restriction the most important public health intervention?
Sunil Kumar Raina MD FIAPSM , Yaneer Bar-Yam Dr RP Government Medical College, Tanda (HP) and New England Complex Systems Institute, Cambridge, MA USA (Dated: February 25, 2021)Indian response to the pandemic has been described from “India is in denial about the covid-19crisis” or “India staring at corona virus disaster”, to “The mystery of India’s plummeting covid-19cases”. These responses have been far from being backed scientifically and appear ignorant of India’scapabilities of leveraging its strengths to mitigate the impact of the pandemic. Backed by a swiftGovernment action of restricting/regulating movement to increasing public health capacity to meetthe increasing demands of the pandemic, India seems to have done enough to emerge successful.India is doing well, if not guaranteed for the future, but at least for now. Here we review thesemeasures and point to their consistency with analysis of the role of intercommunity transmissionand within community action to stop localized outbreaks. In particular, severe restrictions on travel,stopping gatherings, targeted localized lockdowns, school closures, effective public communication,improvements in case identification, rapid ramping of industrial production of masks and otherpersonal protective equipment (PPE) and testing capacity, as well as intensive measures in highdensity areas of urban deprivation have placed India in a regime of declining cases and outbreakcontrol. It is time to recognize the scientific basis of India’s success and give it its due. With thenumber of new cases in India leveling recently, the urgency is great to complete the eliminiationprocess so that a new surge does not occur.
I. BACKGROUND
Over one year into the COVID-19 pandemic there con-tinue to be widely speculative ill-informed discussionsof causal factors in pandemic dynamics despite scientificclarity about the essential role of public health measures.Some of the most common questions doing the roundshave been; was use of stringent lock down measures nec-essary? Why did it strike different countries differentlyor different states/cities in the same country with vary-ing severity? In between such questions there have beenheadlines that read that “India is in denial about theCOVID-19 crisis” or “India staring at corona virus dis-aster”. [1] Surprisingly however, the last few months haveseen a new narrative on India. The headlines now read“The mystery of India’s plummeting covid-19 cases” al-though the word “mystery” is far from flattering.[2] FromIndia’s efforts in mitigating the impact of Covid-19 pan-demic being viewed with suspicion to India’s success nowbeing equated with magic, the cycle of mis-informationon India seems complete. Epidemiological experts andthe mathematical modelers alike were predicting millionsof deaths by August 2020, the falling numbers have leftthem perplexed and seeking non-scientific or still specu-lative explanations such as a hygiene/microbiome theorythat has been widely talked about as the factor workingin India’s favor [5] and the country’s age profile havingplayed a positive role—which perhaps contributed to alower death rate but does not explain why cases have de-clined. The achievement has been spectacular. As on 8thof February, India, with a population of 1 . ,
080 COVID-19 deaths with 84 deaths inthe preceding 24 hours and total number of active casesis at 148 ,
609 is doing much better than in comparison to, the United States, which has seen 439 ,
830 deaths orthe United Kingdom for example, countries boasting of asuperior healthcare delivery system. [3] We note that nopositive correlation between superior healthcare deliverysystems with pandemic excellence has been shown, andindeed, there is no reason to attribute effectiveness ofprevention through stopping transmission to the medicalquality or capacity of hospitals for treatment of infectedindividuals. Public health prevention and medical treat-ment are entirely different capabilities.
II. THE EVIDENCE SO FAR
India recorded 97,859 on 16th September 2020, thehighest single-day number of Covid-19 infections sincethe start of the pandemic. However, ever since then thecases have seen a significant decline despite the number oftests being carried out continuing to be substantial. TheIndian Council of Medical Research (ICMR) backed test-ing strategy had yielded 8 crore (tens of millions of) teststill 30th September out of which 3.1 crore were done inSeptember only with a daily average of 10 , ,
750 tests.As recent as 13th of February, the total number of testsconducted was 6 , ,
114 to add to a cumulative total of20 , , , , III. WHAT HAS WORKED IN INDIA’S FAVOR
In an attempt to look into what may have worked forIndia, we list a few important underlying factors proba-bly favorable to mitigating the impact of the pandemic.1. Experience and successful response efforts in priorpandemics has been in India’s favor. India sawlesser number of cases of 2009 H1N1 pandemicdue to H1N1pdm09 virus when compared to theUnited States or the Europe or even Africa for thatmatter. [6] It even saw lesser cases than China,Japan or South Korea.[6] The evidence of historyalso reveals India’s ability to largely restrict pan-demics/epidemics to one or few geographical ar-eas only. Even the Spanish flu of 1918 which issupposed to have hit India badly killing an esti-mated 10 million to 20 million—roughly 6% of theIndian population at that time—did not present adifferent picture, with the then state of Bombayaffected badly in comparison to Bihar for exam-ple. [7] Similar observations appear to be the storyfor seasonal Influenza A (H1N1) where the casesare differentially distributed across the country.[8]We note that Covid-19, did affect India widely andregistered a large number of cases. However, hereagain the highest contribution to cases in this pan-demic has also been restricted to some regions only.The reasons for the observed geographical restric-tion can be attributed to both underlying socialconditions as well as proactive implementation ofpublic health measures as enumerated below.2. The less urbanized India may have worked to its ad-vantage. Of all the continents in the world, Asia isthe least urbanized, with 51% of its population liv-ing in the urban areas. [9] When it comes to India,the percentage falls further with only around 30%of Indians living in Urban areas. [10] When com-pared to Europe or America, the difference is signif-icant. A large portion of Indian population surviveson agriculture as main source of income generation.This results in limited travel and thus limited ratesof community-to-community transmission and theopportunity to implement localized actions to stopoutbreaks from spreading further.3. Another important factor that probably workedin India’s favor is the way Indians travel. In-dia continues to use buses as the major pub-lic transport mode of travel. Rapid transit(metro/subways/undergrounds etc) travel mode isrestricted to a few major cities of the country only.So is travel by the airways. Added to it is the factthat large India states like the Uttar Pradesh or Bi-har which account for almost 1/4th of India’s popu-lation travel less in comparison to states like Keralaor Himachal Pradesh leading to less overall meantravel time by Indian population in general. As per a report, 86% of Indian households never taketo a trip.[11] The limited modes of travel both limittransmission between communities and allow for itsregulation when proactive measures are taken.4. The fact that India does not feature among the toptourist destinations of the world may again havehelped. [12] India’s international tourist footprintis very small in comparison to France for exam-ple. The fact, however, remains that India fea-tures at rank 8 among the top 10 tourist desti-nations in Asia-Pacific.[12] The tourism is, how-ever, localized—large parts of north and northeast-ern India (wherein impact of Covid-19 pandemicwas lower) boast of very few international airportsand fewer direct international flights. Significantly,Kerala, a state which continues to have a high num-ber of cases has four international airports, whileby comparison there is one in the state of Bihar andtwo in the state of Uttar Pradesh.[13]
IV. HOW INDIA LEVERAGED ITS STRENGTH
Credit must go to the country’s policy makers on theirability to identify its strengths and leverage these to theiradvantage.1.
Lockdown and Zoning : Use of non pharmaceu-tical interventions by imposing large-scale restric-tions on gatherings where person-to-person trans-mission could occur was probably the most effectivestep taken by the Government. Some of these re-strictions continue to be in place across large partof the country restricting social gatherings. As In-dia’s Prime minister said in one of his meetings withthe Chief Ministers of different states at the end ofApril 2020, the government may move towards a“smart lockdown”—with severe restrictions in af-fected districts, and partial lifting of restrictionsin unaffected districts, along with the opening upof some sectors to meet the economic challenge.[14] This was done by demarcating the countryinto three types of zones—red, orange and green—depending on the scale of the Covid-19 outbreak.While no activity was allowed in the red zone,minimum activities like opening of limited publictransport, harvesting of farm products were allowedin orange zones (where only few cases had beenfound in the recent past), and further relaxationlike opening of MSME industries falling with in-house lodging facilities for employees with propermaintenance of social distance was allowed in greenzones. [14] India is continuing to rely on this modelof both restriction and regulation on the one handand of relaxation on the other. The state of Maha-rashtra which has seen a rise in cases again is con-templating imposition of a new lockdown. [15] In astatement on 17th of February 2021, the chief min-ister of the state of Maharashtra minced no wordswhile addressing a meeting with the Revenue Com-missioners and Collectors through video conferenc-ing, when he said that “It is up to the people to de-cide whether they want the lockdown back or roamfreely with some restrictions and if people do notwear masks or follow health rules, then the districtand police administration has a responsibility tostrictly enforce these rules. They must take strictpunitive and necessary action without showing anyleniency,” Thus, imposing restriction and localizingcases to specific geographical locations is continu-ing to be seen as an effective tool to counter theimpact of the pandemic.2.
Restriction on travel : For the large part of2020, the country saw restrictions on travel. Travelwas regulated through issue of e-pass with borderchecks in place on state borders across the coun-try. The regulation of travel continues into 2021as travel has not been fully de-regulated. In a fewstates/union territories like Jammu & Kashmir orUttarakhand for example, every traveler is regis-tered before entry or either needs to show Covid-19negative test report or undergo a test for the infec-tion. As late as 31st of January 2021, all 20 districtsof the Union territory of J&K were listed in orangezone with only regulated activities allowed.[16] Theguidelines on international travel continue (as of17th February 2021) to be in place with travelersrequiring to undergo quarantine after entering In-dia in addition to production of RT-PCR negativetest report.3.
Immediate isolation and contact tracing ontesting positive : The country continues to useits strategy of restricting mobility and isolating allindividuals who test positive to Covd-19. Restric-tions are imposed on their movement and contacttracing is conducted. All primary contacts identi-fied as high-risk contacts (as per the defined pro-tocol) are also quarantined and tested. The move-ments of contacts are restricted till they are con-firmed to be negative. Quarantines of locations(not just of individuals) are also applied: Thearea/building or site is sealed off if the cases comein a cluster. In one such case when 14 inmates ofan old age home in the state of Himachal Pradeshtested positive on 31st of January 2021, a 50 meterarea around the old age home was completed sealedoff and contained. [17]4.
School Closure : For an extended period of time,all Indians up to age 25 were at home, there wereno schools and no colleges open. Recent reopen-ing is partial and occurs in a context of very lownumber of cases. The current reopening strategy,due to its recent nature, remains untested in itsepidemiological consequences [21]5.
Industry response : Another area wherein In- dia showed tremendous progress within a short pe-riod of time was manufacturing. The industry re-sponded to the needs of the pandemic like never be-fore. From a country producing no high-end masksand personal protective equipment to its capabilityof being able to supply to the world, the shift wasswift and decisive. [18] In fact, the production ofpersonal protective equipment (PPEs) went fromzero to the second-highest in the world within twomonths. The incentives by the Government workedas a boost as it itself went into procuring and dis-tributing ventilators.6.
Laboratory Testing Capacity : From a singlelab capable of doing RT-PCR for Covid-19 to morethan 2300 (in both Government and Private sector)has been a significant public health initiative.[4]The addition of a greater number of labs has re-duced the test result return time, strengthening theisolation/quarantine strategy.7.
Awareness : The public awareness drives withcautionary messages replacing ring tunes on phonesto imposing fines for not wearing mask in public,public communication and response efforts movedin sync. More awareness meant that the generalpopulation willingly submitted to the restrictionguidelines. Typical Indians travelled significantlyless in 2020 than the past few years.8.
High density urban areas : The greatest chal-lenge to pandemic response is the areas of urbandeprivation. India’s response therein involved lo-cal intensification and refinement of the lockdowns,travel restrictions, rapid case identification, andpublic communication found in other locations.For, e.g. Dharavi, one of the largest slums in Asia(2.1 km , about 1 mile on a side) and 1M peo-ple, the area is treated as a separate administra-tive zone with an Assistant municipal commissionerin charge. 3 , ,
600 were screened, 9 municipaldispensaries and 350 private clinics were pressedinto service, 225 community toilets, 100 public toi-lets, 125 MHADA toilets were disinfected daily.Anybody in these blocks that has any problemsis reported to the 350 local health workers, theyrespond and provide isolation away from home.Quarantine facilities were established in schools,hostels etc. Communication is strong across thecommunity that if there are problems to get testedand isolated as soon as symptoms are found. Thereis restricted entry and exit from these areas. Simi-larly, for multiple zones of slums in Delhi.[20]9.
Vaccines : Through what is being recognized asthe largest vaccination drive across the world, thegovernment of India on 16th of January started vac-cinating its healthcare professionals, riding largelyon two vaccines developed by Indian vaccine man-ufactures.[9] This action, reflecting an all measuresapproach, is expected to have a increasingly signif-icant impact on the outbreak.
V. WHAT INDIA NEEDS TO CONTINUEDOING
In order to further reduce the number of daily casesof Covid-19 being reported, India needs to strengthenwhat it has been doing so far. It needs to continue withregulation/restriction in areas reporting cases while al-lowing return to normalcy in areas reporting no cases.It also needs to respond quickly to every single case ofCovid-19 reported from any part of the country by iso-lating the case, carrying out contact tracing and placingrestriction of movement on those suspected to carryingthe disease. Also, it needs to strengthen its Covid-19vaccination strategy as it does not have a general adultvaccination program in place. As the country intendsto vaccinate 300 million individuals by July 2021, a vac-cination strategy integrated into the pandemic responseprogram may be helpful.Still, the difference between success and failure in pan-demic response rests on decisiveness of action when num-bers of cases are small. Recent numbers of new cases inIndia have leveled at around 11,000 cases per day withapproximately half in Kerala. The outbreak there shouldbe finally controlled. Elsewhere, and there, the urgencyis great to complete the elimination process so that anew surge does not occur across India. Should India joincountries in Asia and Oceania in elimination, 50% of theworld would become COVID free and an example foremulation can be achieved that is surely unexpected bywestern observers.
VI. LESSONS FOR THE WORLD
At the end of Spanish flu of 1918, the SanitaryCommissioner of India reported “Transportation systemsaided the spread of the disease as the railway played aprominent part as was inevitable”. [7] The Covid-19 pan-demic has not behaved differently. Travel and time oflocal response are the key components of this pandemic’soutcomes. The message to go out from India therefore is“restrict travel in areas wherein cases are there, isolatecases and don’t allow them to transmit infection”. Thestates that continue (to date) to have some restrictionson travel did better than others in India. Kerala, was theone state that opened up early, as early as April 2020,and distinct from other states continues to have signif-icantly more cases. Probably also the fact that Keralasaw the largest number of expatriates coming back fromoutside the country could be a contributing factor. Of al-most 8 lakh expatriates coming to India more than 25%belonged to Kerala.
VII. CONCLUSIONS
Travel and time could be the key for controlling pan-demics. India, with less travel externally and internallythan its western counterparts due to both intrinsic condi-tions and public health measures gave itself more time toget the infection under control than much of the westernworld. Under these conditions, where localized restric-tions are not needed, relaxing restrictions can be donewithout preventing effective control measures in otherlocations, resulting in overall ongoing reduction in cases.That those who are not aware of the geographic dynamicof response efforts do not recognize it is not surprising,but the scientific and public health understanding shouldbe clear. [1] India Is in Denial about the COVID-19 Crisis. Availableonline at:
Last accessed:18-02-2021.[2] The Mystery of India’s Plummeting COVID-19 Cases.Available online at: flutrackers.com . Last accessed: 18-02-2021.[3] WHO Coronavirus Disease (COVID-19) Dashboard.
Covid19.who.int . Last accessed: 18-02-2021.[4] . Last accessed: 18-02-2021.[5] Kumar P, Chander B. COVID 19 mortality: Probablerole of microbiome to explain disparity. Med Hypotheses.2020; 144: 110209.[6] 2009 swine flu pandemic by country—Wikipedia. Avail-able online at: en.wikipedia.org . Last accessed: 18-02-2021.[7] A study maps the spread (and decline) of the 1918 Span-ish flu in India. Available online at scroll.in . Last ac-cessed: 18-02-2021.[8] Seasonal Influenza H1N1. Available online at ncdc.gov.in . Last accessed: 18-02-2021. [9] Population of Asia (2021)—Worldometer. Available on-line at: . Last accessed: 18-02-2021.[10] Census of India 2011 Urban Agglomerations and Cities.Available online at
Censusindia.gov.in . Last accessed:18-02-2021.[11] How many Indians travel?—Mint. Available online at [12] World Tourism rankings—Wikipedia. Available onlineat: en.wikipedia.org . Last accessed: 18-02-2021.[13] List of all International Airports of India. Available on-line at: . Last accessed: 18-02-2021.[14] A smart lockdown, HT Editorial. Available online at: . Last accessed: 18-02-2021.[15] Want freedom or lockdown? Maharashtra CM UddhavThackeray warns over rising Covid-19 cases. Availableonline at : . Last accessed: 18-02-2021[16] Jammu and Kashmir extends Covid-19 Lockdownrestrictions till January 31. Available online at: . Last accessed: 18-02-2021 [17] Coronavirus: Twelve tested positive at old-age home inMcLeod Ganj. Available online at:
Last accessed: 24-02-2021 (and order by Office of Sub-divisional Magistrate Dharamshala District Kangra Hi-machal Pradesh 601 /COVID19/SDK/031.01.2021)[18] From struggling to meet domestic demand, to exporting,India’s PPE manufacturing tale is one of self-reliance.Available online at: . Last ac- cessed: 18-02-2021[19] Raina SK, Kumar R. “Covishield and Covaxin”—India’sContribution to Global Covid-19 pandemic. Jour of FamilMed Prim Care. (in production)[20] Golecha M. COVID-19 Containment in Asia’s LargestUrban Slum Dharavi-Mumbai, India: Lessons for Policy-makers Globally. J Urban Health (2020) 97:796-801).[21] COVID-19: Over 1.3 billion students hit by closure ofschools, colleges, says VC.. Last ac- cessed: 18-02-2021[19] Raina SK, Kumar R. “Covishield and Covaxin”—India’sContribution to Global Covid-19 pandemic. Jour of FamilMed Prim Care. (in production)[20] Golecha M. COVID-19 Containment in Asia’s LargestUrban Slum Dharavi-Mumbai, India: Lessons for Policy-makers Globally. J Urban Health (2020) 97:796-801).[21] COVID-19: Over 1.3 billion students hit by closure ofschools, colleges, says VC.