Sunil Singh Narpal Singh Sikh tested positive for COVID-19 on 21 March. The 23-year-old, a migrant from Uttar Pradesh who was working as a daily-wage mason in the state, had been having difficulty breathing and is now scared that he will die, his friend, Pyarelal Yadav, told me. Yadav said Singh would keep crying in his isolation ward, in the Kolhapur district’s Kagal Rural Hospital, where he had been separated from all other patients. “We tried to give him some medicines we bought across the counter at a local medical but he was not improving so we got him to the hospital,” Yadav, who is also a mason, said. They earn between Rs 300–500 per day, and send money to their landless families in their native village of Janghai, near Allahabad. Yadav had been advised to quarantine himself. Before hanging up, he asked in earnest, “Do you think I will also end up like Sunil?”
As the number of fatalities to the novel coronavirus in India reached 19 and confirmed cases rose to over eight hundred, Maharashtra has seen among the highest number of cases in any state. The rapid outbreak of the virus in the state has not been limited to the crowded cities such as Mumbai and Pune, but has affected interior districts such as Amravati and Sangli as well. As of 8.30 am on 28 March, Maharashtra had reported 154 confirmed cases and six deaths, according to state health officials. Public-health experts believe a variety of reasons contributed to the pandemic rising in Maharashtra, ranging from the government failing to recognise the gravity of the crisis, the high-density of population, and a demographic that includes a large number of international travellers.
When the total cases in Maharashtra jumped quickly from 64 to 101 within 72 hours, from 20 to 22 March, the state government went into a huddle and decided to place the state under lockdown. Since 23 March, Maharashtra, like Delhi and Punjab, has been under lockdown, one day before the prime minister Narendra Modi announced a 21-day nationwide lockdown. “Nothing much changes for Maharashtra,” Anil Deshmukh, the state home minister, told me. “People should not panic. The same curfew which was working like a total lockdown will now go on till April 15.” Deshmukh added, “We are working to ensure all essential supplies like grocery, milk, medicines and cooking gas are not affected and people are not inconvenienced. Stepping out in panic to buy essentials and crowding shops and markets will be wrong. We will work that out so that both safety and convenience are balanced.”
According to Dr Anant Phadke, a co-convenor of the Jan Swasthya Abhiyan—a public-health initiative in rural Chhattisgarh—one of the reasons Maharashtra has shown the most cases so far is because it is highly developed and urbanised. He underlined how Mumbai is one of the busiest airports in the country, which connects people to nodal destinations like Kuala Lumpur, Dubai and Amsterdam. “Obviously with that kind of volume of passengers the risk of infection is also that much more.”
Phadke also blamed the manner in which people are tested for the virus at the airport upon arrival. “You’re asked if you have fever, cough or cold. If you say no, they might perfunctorily check if you have temperature and let you go. There is no mechanism in place to monitor whether these passengers can report back if they show symptoms at a later stage,” he explained. “Now, if I have left Italy yesterday, where the coronavirus is creating havoc, I might not manifest symptoms immediately on landing the next day. What the current regimen ignores is how I could still be a carrier and infect others even in that condition.” It is precisely this that led the Punjab administration to allow Baldev Singh, India’s fourth COVID-19 casualty, to enter the state and roam freely, ultimately affecting at least 15 others from his family and village.
A second important reason for Maharashtra’s crisis, according to Phadke, was that passengers coming from Dubai were initially not being checked because it was not listed among the places affected. “But many people fly in from various destinations across the world to Dubai to fly back to Mumbai. And even if they did come from an affected part of the world initially, such passengers were also allowed to go.” Mohan Rao, who was a professor of public health at the Jawaharlal Nehru University’s centre of social Medicine and Community Health for over three decades, identified another problem that emerged from international travellers. “While the arrival from abroad made some believe it was a disease of the affluent, many forget that several of these are also abject poor labourers coming back from Gulf countries,” Rao noted.
While some of the patients who tested positive for coronavirus from Maharashtra had a travel history to South America and the Persian Gulf countries, others such as Sunil Singh had not even travelled out of their workplaces. It is this working-class category of citizens that the authorities are most worried about. “If the virus spreads into the thick, congested slum communities, we will have a full-scale disaster of epic proportions staring at us,” a public-health bureaucrat said, on the condition of anonymity. The bureaucrat then referred to the case of a 36-year-old slum dweller from Mumbai’s western suburbs, who had gotten infected with the novel coronavirus from a couple who had employed her as a domestic worker. “That is the reason the civic officials in Mumbai scrambled to locate and isolate” her, the bureaucrat added. “Her family and neighbours are also being tested. But imagine how overwhelming this task is because she shared the toilet and bath facilities with the entire neighbourhood of over 2,500 people living in a tight cluster.” The civic health-authorities told me that they were struggling not only to find all the potentially infected people, but even to enter all the lanes in the slum colony, some which do not receive any sunlight.
“The immediate reason seems to be overcrowding and pockets of the high-density population even in tier-two and tier-three cities, where lockdowns and social distancing began much later,” Rao told me. He emphasised that the state authorities did not anticipate the magnitude of what was coming their way. “At first, it was being seen as a very first-world problem,” he said. “This was later scaled down to being a disease of the foreign returned. From first assuming that only the elderly were at risk, in the beginning of March, to everybody now potentially in danger, we have come quite a long way.”
Phadke, too, spoke about the government’s failure to prepare itself for the pandemic. “For the first few days both the centre and Maharashtra did almost nothing apart from feeble noises on personal hygiene and washing of hands,” he said. Phadke noted that India’s first case was reported on 30 January, and said the lockdown should have been implemented much earlier. “The lack of holistic policy in the approach to combating the coronavirus is not unique to Maharashtra, but in the way it plays out in sheer numbers, it made a big difference.”
Dr Muffazal Lakdawala, a leading surgeon from Mumbai, lauded the state government for imposing a lockdown, sealing the state borders and stopping all public transport. But Lakdawala added, “I am worried that will not be enough without aggressive and mass testing. Unless we are seized of the actual magnitude of the problem at hand, planning an intervention and management and containment can be difficult.”
Rao echoed Lakdawala’s concerns. He said that tackling any disease needs three strategies: the curative, the preventive, and the promotive—the last of which refers to the lockdown and enforced social distancing . “To understand which of these strategies will work the best, the permutation-combination in which they have to be unleashed will only be clear if we have an understanding of the number of infected people, and the number of people who are not manifesting symptoms themselves but carriers who could potentially infect others,” Rao noted. “For now, all interventions to deal with the infection are only supportive, and prevention aimed at reducing transmission in the community is the best way to go forward. China has seen a sharp fall in new cases in the last few days by ensuring mass swathes of people are isolated. There is some merit to this strategy but doing it in the absence of testing is saying that promotive strategies will work by themselves.”
The state government has also taken other measures in an attempt to contain the spread of the virus. On 16 March, after the Supreme Court took suo-moto cognisance of concerns about COVID-19 spreading through prisons due to overcrowding, and directed state governments to isolate inmates who were showing symptoms, a policy that was first initiated by the Kerala government. On the orders of the apex court, on 23 March, the Maharashtra government appointed a high-powered committee comprising the chairperson of the State Legal Services Committee, the principal secretary of the home department and the director general of prisons, to determine which class of prisoners could be released.
The state has 60 jails with over thirty-six thousand inmates. The nine central prisons—in Mumbai, Thane, Kharghar, Nashik, Pune, Aurangabad, Kalamba, Amravati and Nagpur—are among the most crowded and the home ministry had already asked for the inmates to be shuffled to reduce overcrowding, especially in Mumbai’s Arthur Road prison. On 26 March, Deshmukh tweeted that he had directed the jail authorities to release “11,000 convicts/undertrials imprisoned for offences upto 7 yrs or less on emergency parole or furlough to reduce overcrowding in prisons and contain the risk of a #COVID19 outbreak.”
While the COVID-19 outbreak in India has shown no signs of relenting, the centre has insisted that there is no community transmission of the virus. During a press briefing on 25 March, Lav Agrawal, a joint secretary in the union health ministry, stated, “There is no proof of community transmission as of today.” Phadke laughed at the government’s denial of community transmission.
“The state government put the state on a lockdown but this is literally like closing the stable door after the horse has bolted,” he said. “When people come to me as a doctor and even when I write a referral saying someone should categorically be tested for COVID-19, the staff at the government-run testing facility would say they can’t if the patient has no travel history. On Wednesday”—25 March—“they began to test pneumonia patients too, but there is still no policy clarity on this because some facilities do it and others still don’t.”
Given the number of potentially affected people, Phadke believed that it is only a matter of time before the authorities admit that the outbreak is well into the community transmission stage. “Let us not kid ourselves on this.”