The Dangerous ‘Flattening of the Curve’ in India

Surajit Mazumdar

On 24 July 2020, the Government of India’s Press Information Bureau issued a release on the Union Health Minister’s address to the Shanghai Cooperation Organization (SCO) Health Minister’s Digital Meet on India’s Covid-19 containment strategy. Dr. Harsh Vardhan reportedly paid the customary obeisance to his leader by stating that the PM had “personally monitored the situation and ensured a preemptive, pro-active and graded response to prevent the deadly virus from spreading.” Emphasizing the special importance of the lockdowns announced from March onwards, the Minister went on to remark that “India has so far reported 1.25 million cases and more than 30,000 deaths due to COVID. At 864 cases per million and less than 21 deaths per million of our population, India has one of the world’s lowest infection and death rate. Our recovery rate stands at 63.45% whereas our mortality at 2.3%.” While the rest of this statement was factual even if needing interpretation, the twist was in the use of the expression “the world’s lowest”. This expression actually has somehow managed to retain its status as one of the favourite ones of choice in official briefings throughout the pandemic’s march in India, as has the linking of it to the lockdown decisions and the denial of the setting in of ‘community transmission’. After four months of the country living in the shadow of the epidemic, however, it sounds more and more like a stuck record increasingly at odds with the reality, a desperate attempt to pose as a great achievement what is actually a grim outcome.

Here are some of the facts. India has the third largest number of confirmed cases of Covid-19 infections in the world and the sixth largest death toll. It tops the Asian continent in both by a wide margin, with more than four times the number of cases and twice the number of deaths than the next highest country. Even in per capita terms, it fares poorly with most of the countries in the continent which accounts for 55 per cent of the ‘world’ in terms of population. 28 out of the 49 countries in Asia have lower cases per million population than India while 31 have lower deaths per million. All the countries faring worse than India together account for only a little over half of India’s population, which itself is around 30 per cent of the Asian total. The countries doing better than India correspondingly have an almost 55 per cent share of the Asian population, 1.8 times that of India. Even if we exclude China, the rest of this group has an Asian population share of over 23 per cent.  Whichever way one looks at it, therefore, India clearly falls in the bottom rungs as far as its achievements in protecting its population from the ravages of the Coronavirus are concerned. This, however, if far from being the complete story because the pandemic is not yet over – and the trends indicate that India’s relative position in the world is destined to become even worse than it currently is.

India’s “Flattening of the Curve”

A particularly important figure that is not obvious from the total numbers is the rate at which those numbers are rising every day. The United States and Brazil have more cases than India but the rate at which the daily total is increasing is considerably higher in India. In fact, the Indian rate has for some time been among the highest in the world and more than twice the world average. If we consider the average between the 1st and the 23rd of the month of July, only about 30 of over 200 countries in the world, making up less than 6 per cent of the global population, have had a daily rate of growth of total confirmed cases higher than India’s. In other words, India’s has not only one of the largest outbreaks of the Coronavirus epidemic in the world, it is also currently one of the fastest growing. India’s contribution to the global total of daily cases, at almost 50,000 as per the figures on the morning of 24th July, has already caught up with its share in the world’s population. It seems also destined to increase further unless the rate of growth is brought down quickly. That, however, is precisely what is not happening.

Instead of heading downwards as it did in an earlier phase of the epidemic, the daily growth rate of confirmed cases in India has levelled off, simply refusing to go down any further. This levelling began some time ago rather than recently. In mid-April the rate was over 10 per cent but came down to around 7 per cent by the end of that month. With some ups and downs, it dropped further to around 5 per cent by the end of May and then moved in the direction of 4 per cent in the first week of June. As per the official data issued by the Ministry of Health and Family Welfare (MoHFW) at 8 a.m. in the morning every day, the percentage increase in confirmed cases over the previous day’s total fell below 4 per cent for the first time on 9 June 2020. The apparently good part is it has never breached that 4 per cent mark since. However, it has recurrently threatened to, a reflection of the fact that any downward trend underlying the day to day fluctuations became virtually non-existent thereafter even though one and a half months has since passed (Figure 1). This is the curve, that of the daily rate of growth of cases across time, that India has managed to successfully ‘flatten’. As a corollary, the doubling time of total confirmed cases has also ceased to move upwards – it too has been ‘flattened’.  In the process, however, the flattening of the curve actually needed has continued to elude India – and the growth of cases in India has in fact become ‘exponential’ since the end of the first week of June.

Figure 1: Daily Growth of Confirmed Cases (percentage increase over the previous day) of Covid-19 Infection in India, 9 June 2020 to 25 July 2020)

The absence of a decline in the daily rate of growth of cases will necessarily imply a rise in the number of fresh confirmed cases reported daily, since the base on which the percentage increase takes place increases every day as a result of those new cases. As the number of confirmed cases continue to rise, so too will the total number of deaths even if the fatality rate (the proportion of confirmed cases who do not survive the infection) is low or declining. If a larger proportion of the population in one country is infected than in another, this could also result in it experiencing a higher death toll per capita even if its fatality rate is lower.

Government briefings tend to make a lot out of the fact that the number of those who have recovered from the Covid-19 infection in India far exceed the number of those in whom the virus is currently active. Thus, while 4,56,071 cases were active on 25 July 2020 as per the MoHFW data, the number who have recovered is 8,49,431. This, however, is mainly a reflection of the earlier decline in the daily growth rate. We know that the virus has some typical period of time for which it affects anyone infected, at the end of which there is recovery in most cases as the fatality ratio tends to be low. Active cases on any day are, therefore, always only those who were infected relatively recently (the last two weeks or so) while those infected earlier than that would typically have recovered. The ratio between these two numbers can, however, only keep coming down if the daily growth rate keeps declining. As this has ceased, the decline in the proportion of active cases too has become slower, almost levelling off at the 34-35 per cent level. More significantly, since the total number of confirmed cases is steadily rising, the slowness of the decline in proportion of currently active cases means that their absolute numbers have continued to steadily rise. In other words, the load on the country’s health system is still increasing every day.

Over the course of the epidemic from beginning to end in any country, each of the three variables – the number of cases reported daily, the daily number of deaths and the number of active cases – have to first rise, reach some peak levels and then steadily decline until their levels reach zero or close to zero. The per capita levels of both cases and deaths, however, can only go on increasing until the epidemic finally ends, and no new cases are any longer reported. The more successful a country is in controlling the spread of the epidemic, the lower will be the peak values, the quicker will be the turnaround in the trend and lower will be the eventual per capita numbers of infections and deaths.  In many countries of the world, these peaks were crossed several months ago and much of the downward movement thereafter has been completed, even if they have to keep dealing with fresh outbreaks here and there. India, however, remains on the upward sloping part of each of these curves and will remain so until it can resume the reduction in the daily growth rate of cases and achieve it at a quick enough rate.  

The Levelling of the Growth Rate: Implications

The Implications of the leveling off of the decline in the daily growth rate for what might have been and what may be the case going forward can be appreciated by comparing 4 alternate hypothetical scenarios of the movement of daily cases over time starting from the actual number on 8 June 2020 and the actual levels so far. Scenario 1 represents the situation in which it is assumed that the daily growth rate drops by 0.02 percentage points every successive day from a starting value of 4 per cent – that is it moves from 4 to 3.98 on the first day, 3.96 the second day, 3.94 on the third day and so on. In Scenario 2 we assume that the daily growth comes down by a little faster, by 0.03 percentage points ever successive day – from 4 to 3.97, then 3.94, 3.91. 3.89, and so on. Scenarios 3 and 4 correspond to situations of even quicker decline in the daily growth rate – by 0.04 and 0.05 percentage points, respectively, every successive day.

Each of the four scenarios gives rise to differences in the number of days it would take for the daily growth to reach zero – 200 in the case of Scenario 1 and 134, 100 and 80 for Scenarios 2, 3 and 4 respectively. If 9 June were taken to be the first day, the end dates for the epidemics would then be 25 December, 20 October, 16 September and 25 July. The peak levels of the daily cases and their dates for each Scenario are – 1.11 lakh cases on 15 October for Scenario 1; 36,529 cases on 23 August for Scenario 2; 21,828 cases on 28 July for Scenario 3; and 16,481 on 13 July for Scenario 4. The final figures of the number of conformed cases would be around 130 lakhs (13 million), 35 lakhs, 18 lakhs and 12 lakhs respectively for Scenarios 1 to 4.  

Figure 2: Movement of Daily Cases of Covid-19 from 9 June Onward under Alternative Scenarios

Figure 2 shows how the number of fresh confirmed cases reported every day would have moved from 9 June onwards till 25 July and thereafter for each of the four scenarios until the daily growth reached zero. The trajectory of actual cases over the last one and a half months which is also shown makes it clear that India has been unable to even achieve circumstances approximating Scenario 1. This is the scenario in which the peak level is destined to more than double from that reached thus far, and the final tally of cases and also therefore deaths to be ten times their current figures. It also shows how distant the country has been from the other three scenarios which would have brought it closer to the end of the epidemic by now, with lower peak values than those India has already crossed, and considerably lower final figures. Indeed, what might appear at first sight to be small differences between the different scenarios actually mean a lot and this also puts into perspective the implications of India’s daily growth rate levelling off at more than twice the world average. 

A Cruel Joke

The levelling off of the daily growth rate of cases in India reflects a recurring double failure of India’s national containment strategy. The first is the inability to bring outbreaks of the epidemic in any part of the country under control quickly and decisively enough, before the numbers multiply too much.  The second is the failure to control the spread from initially affected populations to other parts of the country or other regions in the same state. If we look at the picture across states, the evidence indicates that at different stages in the history of the epidemic, different groups of states have been more prominent than others in driving up the numbers. Now, however, the daily numbers are spiralling upwards in almost every state, most rapidly in some where things appeared to have been under control some time ago. In many of the states, newer cities and districts rather than the ones most affected earlier, are becoming significant in pushing up state numbers. These are symptoms of a macro level failure for which the principal responsibility rests with the acts of commission and omission of the Central Government, including inadequacies in its support to State Government. 

As things stand today, India is staring at the prospect of reaching within the year 2020, and before any vaccine can be available, extremely grim milestones of over a lakh cases per day and anything between 2 to 3 lakhs deaths due to the Coronavirus pandemic. Correspondingly, added dimensions of the crisis – like the inability of the health system to address illnesses other than Covid-19, the devastating effects on economic activity and livelihoods, and the even greater standstill situation in the sphere of education – are also threatening to last much longer and inflict more damage in India than in many other parts of the world. The levelling off seen in the growth rate of cases and the duration it has already lasted stand testimony to the fact that the country need not have reached this situation and could still avoid the worst-case scenarios. The tragedy is that India has a Government which instead of acknowledging its failure and showing a willingness to correct it, has other priorities – which are all about strengthening the ruling regimes power and control, favouring the classes and cronies who bankroll it, and punishing and persecuting those who are politically opposed to it.

As part of its political gamesmanship, the ruling regime’s propaganda machine is also playing a cruel joke on the Indian people by trying to portray what is actually a colossal failure in dealing with the pandemic as one of its crowning achievements. The tragedy is compounded by the fact that much of India’s supine media is unwilling to call this out. It highlights if at all only the micro tragedies and failures, of which there are obviously many instances. The media is also content with shifting the major responsibility for rising cases, either directly or through the opinions of ‘experts’, to the public at large and their supposed laxity in maintaining ‘distancing’ and other norms of prescribed behaviour. That the Government may have failed to ensure the conditions where it would be possible for people to manage and sustain their lives without risking themselves and others to the risk of exposure is a possibility that doesn’t quite cross their minds. That the creation of the capacity for testing, tracing, isolation and treatment may not have been rapid enough in relation to the growth of cases and therefore failed to check that growth and its effects is something that they do not even examine – they are content with hearing that the numbers of these components are also rising. What remains obscured behind these rising numbers of things like tests is that all the requirements of these known ways of dealing the epidemic are progressively becoming bigger in magnitude  but also increasingly difficult to meet precisely because the epidemic has not been brought under control. The slower is the response and greater is the unwillingness to aggressively throw resources in their direction, therefore, the bigger the demands and the shortfalls also become, and this is hardly the indicator of success. In every sense of the term then, India could end up paying an extremely high price for the misplaced ‘decisiveness’ of its current political leadership.          

The author is Professor at CESP, JNU, New Delhi