Cabinet secretary Rajiv Gauba has written to state governments urging them to put under surveillance some 15 lakh travellers who arrived at India’s international airports from January 18 to March 23, and whose details are with the Bureau of Immigration. Not doing so, he says, may seriously jeopardise India’s effort at containing the spread of Covid-19.
Presumably these 15 lakh people were screened at airports and advised “home quarantine”. Those under home quarantine advisories have to be “monitored” by the governments of the states they live in. The letter says “there is a gap between the number of international passengers who need to be monitored, and the actual number being monitored…”
India’s entire Covid-19 containment strategy is centred on passengers arriving from abroad. It appears to be designed to keep tabs on likely carriers, and testing them only if they show the symptoms of a coronavirus infection. Quarantine is an important part of this strategy. However, it seems not to have worked. While the government adopted an extremely conservative testing regime (India has among the lowest rates of testing in the world, by a wide margin), it also appears to have adopted a conservative quarantine regime.
Over two months after it began responding to the rapid spread of the disease across the world, India’s plan now seems designed to fail.
Flight from Wuhan
On February 3, India triumphantly evacuated two planeloads of students from Wuhan province in China, the epicentre of the Covid-19 outbreak. Much was made of the excellent facilities set up by the military for their quarantine. The government, it seemed, was taking responsibility for its citizens and ensuring that public health concerns were addressed to a high standard, with all the evacuees quarantined for 14 days in various government facilities. The crew and doctors who were properly equipped with safety gear were quarantined for a week.
It seemed in that moment that as the world was trying to catch up with what was now likely a quickly spreading contagion, India had established a way to handle it. The novel coronavirus had originated in Wuhan, but by mid-February was rapidly spreading across the world. India recorded its first positive case, in Kerala, on January 30. The sense of a well-thought-out, purposeful and rational plan to contain the spread in India dissipated quickly.
The protocols followed for the Wuhan evacuees, it was quickly established, were a one-off. The government claims that it was screening international travellers arriving in India from January 18, but there is no advisory to this effect. Its travel advisory dated January 17 is about what people travelling to and from China must do in case they felt unwell in different situations. It does not mention airport screening of all passengers from China.
The government’s travel advisories between February 26 and March 16 suggest a hesitant expansion of airport screening and quarantining of passengers travelling from overseas. This is strange given the government’s very minimal testing regime was entirely foreign-travel linked.
On February 26, a Ministry of Health travel advisory states for the first time, “People travelling to China henceforth will be quarantined on return”. It adds that people returning from South Korea, Iran and Italy “or those having history of travel to these countries may be quarantined for 14 days on arrival to India”. Japan – which at that point had double the number of cases as Italy was inexplicably excluded.
Five days later, on March 2, another advisory now referred to China, South Korea, Iran, Italy and Japan as “Covid-19 affected countries” and stated that people arriving from all these countries “will be quarantined”.
A Bureau of Immigration advisory on March 3 said, “Passengers (foreign and Indian) other than those restricted, arriving directly or indirectly from China, South Korea, Japan, Iran, Italy, Hong Kong, Macau, Vietnam, Malaysia, Indonesia, Nepal, Thailand, Singapore and Taiwan must undergo medical screening at port of entry.” At this point, based on the previous advisories, compulsory quarantine is in effect for people from the first five countries on the list.
No mention of quarantine
In its “consolidated advisory” of March 6, the ministry, does not mention quarantine. The advisory, which includes information on the suspension of visas issued to passport holders of five countries states, “Indian citizens are advised to refrain from travel to Covid-19 affected Countries(China, Republic of Korea, Islamic Republic of Iran, Italy and Japan.” It includes only generic advice: “If you feel sick within a span of 28 days after return from Covid-19 affected areas: Immediately call the Helpline number…and follow the direction issued….Maintain effective self-isolation at home and with others...”
The March 6 advisory also, for the first time, stipulates that “all international Passengers entering into India are required to… undergo Universal Health Screening at the designated health counters at all Points of Entry”.
The ministry’s March 10 advisory specifically on home isolation states: “…all passengers having travel history to China, Hong Kong, Republic of Korea, Japan, Italy, Thailand, Singapore, Iran, Malaysia, France, Spain and Germany are advised to undergo self-imposed quarantine for a period of 14 days from the date of their arrival.” Was compulsory quarantine suspended or was this just a bureaucratic oversight while cutting and pasting details of the advisory?
In its consolidated advisory issued a day later on March 11 this is what the ministry says: “All incoming travellers, including Indian nationals, arriving from or having visited China, Italy, Iran, Republic of Korea, France, Spain and Germany after 15th February, 2020 shall be quarantined for a minimum period of 14 days. This will come into effect from 1200 GMT on 13th March 2020 at the port of departure.” Were people to be quarantined by the governments of the country at their port of departure? Or again was this just sloppy drafting?
And then a few days later on March 16, the date on which it announced a ban on all passengers from Europe and Turkey, and after the WHO has declared Covid-19 a global pandemic, the ministry “expands compulsory quarantine” to four more countries – Kuwait, Oman, Qatar and the UAE. This is the first time “compulsory quarantine” is used.
Did the government follow its own advisories? Two illustrative examples may help understand where the problem lies.
Example 1: A 33-year old researcher (now treated as Odisha’s case number 1) arrived in Delhi on March 6 from northern Italy, the epicentre of the Covid-19 outbreak in that country. This was four days after the March 2 advisory that put travellers from Italy on the compulsory 14-day quarantine list. The man travelled to Bhubaneswar on March 12, prior to which he stayed at three different locations in New Delhi.
Example 2: The 25-year-old son of a railway official, who arrived in Bangalore from Germany via Spain on March 13, was advised to quarantine himself at home, which he did not do. He was tested positive five days later. The ministry’s March 11 consolidated advisory includes passengers from Spain and Germany among those undergoing “a minimum 14 day quarantine”. The advisory on March 10 only “advised” travellers from both these countries to “undergo self-imposed quarantine”.
It is clear from the known cases of passengers who ignored the advice to home quarantine, that “quarantine” in the many advisories did not actually mean compulsory quarantine in a state-run facility. In the vast majority of cases, passengers coming from what were clearly new hotspots of the contagion were merely advised to home quarantine. Official quarantine in a state facility was restricted to those with symptoms, and likely only people with symptoms who arrived on direct flights from specified countries.
Even more importantly universal screening was introduced belatedly and there were no universal quarantine advisories, as if viruses confined themselves to national boundaries.
Given the general state of the public and private health system, and clearly aware that India simply did not have the basic capacity – an adequate number of test kits – to test sufficient numbers of people, the government of India adopted a very conservative testing regime. The World Health Organisation has consistently advised countries to “test, test, test”, anyone with symptoms – which are not so very different for those of influenzas. In India, however, you have to have a recent travel history and symptoms, or to have symptoms and direct contact with someone with a recent travel history, or to be very sick with pneumonia, to get tested.
This conservative testing regime, we can extrapolate, was to be backed by a regime of quarantine. But as we have seen the rules of quarantine were narrow and quite loose. It is really home quarantine that was to have carried this policy.
Looked at from any angle those making the decisions, designed a policy of containment relying on two things. First the wisdom and social responsibility of the general public, and second on a very efficient and well-oiled administration.
With respect to the first, it take a special kind of magical thinking to assume that people will behave differently because they are advised to do so. The home quarantine policy ignored an everyday truth about people – that most people are not socially responsible or voluntarily rule abiding. We know from the cases in other countries and of absconding foreign tourists in India that this is a universal problem. We also know that senior civil servants and even doctors can show the same lack of wisdom and social responsibility. We have ample proof of this from the publicly known cases of home quarantine violations in the last three weeks.
With respect to the second, as “home quarantine” was clearly to be the pivot of the containment plan, the government incredibly had no system to check if a passenger went directly into “home quarantine” from the airport or travelled to other towns and cities by domestic flights, trains or buses, staying in hotels and eating in restaurants along the way. Remember that a young IAS officer who was advised home quarantine claims that he understood this to mean he could travel to his family home in another state.
Ignoring road blocks
Given the state’s very limited and regionally variable administrative capacities, decision makers in Delhi were clearly ignoring the obvious road blocks. The southern states, particularly Kerala, but also Karnataka and Tamil Nadu have, in the circumstances, done a reasonable job of tracking and monitoring home quarantine cases. Outside of the five southern states, including in Delhi, it is anyone’s guess what is actually going on.
The combination of the minimal testing regime and a hard-to-enforce quarantine policy lead to the unavoidable conclusion that the government of India’s Covid-19 containment policy was designed on a wing and a prayer.