Sometime back,
the post “Rationality
of Indian Testing Strategy and Chinese Flu” examined the course of Indian
testing strategy and philosophy in reference to diagnosis of the Chinese flu. The
synopsis of the post was summarized as ‘Contrary to the demands of the testing
mafia, the focus should be on testing large numbers in areas worst affected by
the Chinese flu rather than blind and random testing across the country’. The post
had concluded that the then strategy of conservative testing was working well
given the Chernoff bound and thus little need existed for the change as
suggested by certain groups. In a recent post, “The
Impossible Trinity of Chinese Virus”, it was posited an existence of an
impossible trinity. A country cannot have conservative testing, open economy
and low reproduction ratio simultaneously. These two posts at some level appear
to contradict each other. As with any event, facts emerge necessitating a
change in approach. The thought process is dynamic and hence perhaps at this
juncture the debate on testing needs to be examined to validate or otherwise the
conclusions derived from the past posts.
To be fair,
India’s performance so far in its battle against the COVID-19 has been
exceptional. The fatality rate officially is around 2.1% with the death
incidence being under 30 per million. This is in contrast to countries like
Belgium with around 900 per million, UK with around 700 per million or even US
with around 460 per million. Further the total number of cases in India are
fairly less compared to the rest of the world. The total number of cases might
seem high in absolute terms but one has to factor in the Indian population as
well. Contrary to doomsayers, India seems to have escaped the worst, the
reasons for which might be many. If the deaths in India were to follow a trajectory
of some of the European or American countries, India would have been
experiencing at least half a million deaths with the worst scenario being close
one and half million deaths. These in fact had been the projections by many a
naysayer. But these naysayers have been proved wrong is testimony to the much
maligned Indian administrative and governance capacity.
However, there
comes a stage wherein the society has to look beyond and achieve a closure.
India has a population of 140 crores and at even low reproduction ratios, the
cases will continue to spread to larger areas. This is accentuated by the fact
that economy has opened up and needs to be opened up further going forward. An economy
in half-open mode will not be able to sustain for pretty long and brings with
it numerous complications. Therefore, as economy needs to be spruced up, the
Chinese flu must be contained.
The past posts
have argued that South Korean strategy of testing was an outcome of
circumstances and not deliberate choice as advocated by few. The initial
outbreaks made it near impossible for the authorities to engage in contact
tracing without explosion in the numbers. The infection was outpacing the
ability to contact trace. Therefore, a mass testing was the only rational
choice available. In fact, to their credit, South Korea managed to control the
outbreak by testing just about two percent of the population. In contrast, the
European countries have tested anywhere between 10-20% and more. Countries like
UAE have tested nearly a third of their population. At this juncture India is
close to testing 1.5% of its population. The current rate will require nearly a
year to test around 15-20% of the population comparable to the Western
countries. Given the possibility of infection outpacing testing, the numbers to
be tested will have to be increased to manage the outbreak.
India too faces
a similar moment like South Korea. Indubitably, daily testing in India is only
perhaps second to the United States. India is testing around 5-6 lakhs per day.
Yet given the population size, it is hardly sufficient. At this juncture, what
is important is to identify early the positive patients whether symptomatic or asymptomatic,
isolate them thus limiting the spread. Furthermore, as the economy opens, it is
difficult to keep the people movement at bay. States like Karnataka or Andhra
Pradesh or even Assam have faced outbreaks only because of this movement into
the state from the other places. Quarantining the population on the large scale
is becoming impossible both from the infrastructure point of view as also the
monitoring point of view. Besides, the propensity to follow the rules in India
is relatively low compared to countries say Japan. The high population and the
close proximity with which people live in the country add to the woes of
enforcing social distancing.
This is the
stage wherein India needs to break away from the conservative testing model, a
fact highlighted in the past posts too. India needs to scale up its testing to
a large scale. India needs to be testing around 20-25 lakhs per day so as to
cover one percent of the population per week and reach around 8-10% in about 10
weeks. This should by and large bring under control the positivity rate and
keep abreast of the reproduction ratio. The hindrance to this more than the
infrastructure is the policy governing the tests itself.
ICMR has been very
conservative in approving the tests. They are keen to ensure the tests have near 100% accuracy something
possible only with RT-PCR. The other tests including rapid antigens are not
100% accurate and hence ICMR suggest the repeat testing of all those tested
negative under alternative test with RT-PCR for confirmation. This in many ways
has been barrier in the Indian testing process. In South Korea, this was given
a go-by. The focus there was to get the positives as fast as possible without
bothering about perfection. Type I errors or Type-II errors could be corrected
through repeat testing but search for a perfection would have led to loss of
time. This is the stage in India. Further loss of time would make our task
difficult. Many a times, perfection becomes the enemy of the good and the ICMR
policy currently is on the way towards the same.
ICMR should open
up and liberalize the testing including testing without prescription and
testing through multiple mechanisms. If there are doubts about the veracity of
the results, the tests can be repeated. India must move to testing on demand.
ICMR must approve other testing labs to offer their products to customers and
not restrict to the current set of things. The private labs must be involved in
wider way. Price discrimination through second degree must be encouraged with
those who cannot afford the fees be tested in the government labs set up at
different places accessible to all. Strategies must evolve to the changing
context and it is one such situation which demands action from ICMR.
There is
increasing fatigue over the pandemic. People are getting restless and want to
get on with their lives. Yet the fear of contraction and possible mortality
keeps them away. They want some solutions in sight. There is growing perception
that a vaccine would be available by August 15 though it is extremely unlikely.
The earliest the vaccine is likely to be available as the current trends would
indicate would be perhaps early November with access to common men and women by
end December or early January. In this context, the only way to defeat pandemic
apart from social distancing and wearing masks would be very rapid testing. Very
high levels of testing would ensure the testing outpaces infection. If a
country or a region reports higher positivity rate, the only way it can be
brought down is through increased testing. Therefore, at a positivity rate of
around 9%, it is important to increase significantly to bring it down to around
5%. In fact, in this context, rather than the time consuming RT-PCR despite its
accuracy, other tests like rapid antigen testing would be in order. Delhi for
that matter seems to have come under control only through this mechanism. UP
and Assam are couple of other examples of this strategy being adopted. Any
delay might prove politically costly and thus it is in the interests we talk
about tests on demand irrespective of the tests. Testing need not just be once
but many times if demanded by a prospective patient. This seems the only
feasible way to overcome the COVID woes.
Comments
Post a Comment