India's Coronavirus Cases Increase as National Government Relaxes Rules

Map of coronavirus hotspots

Q&A with Bhramar Mukherjee

Professor and Chair of Biostatistics

Despite India's drastic nine-week shutdown and amid relaxing restrictions, the country now has the fourth-largest number of coronavirus cases in the world.

Bhramar Mukherjee, professor and chair of biostatistics at the University of Michigan's School of Public Health, leads the COV-IND-19 Study Group, a team of researchers that, as the coronavirus pandemic unfolded, built real-time data for authorities and the general public in India to visualize and quantify the spread of the virus.

Mukherjee, who is originally from India, discussed her team's work earlier this year. She offers an update to the troubling trend.

What are your models telling you as of right now for India?

The number of cases in India are slowly but steadily rising every day. India's population is only second to China. China was able to contain the epidemic to mostly one province and it did not spread as widely as in India. I wish I had more positive messages but our modeling shows that by July 1 we'll see around 600,000 cases in India.

In other countries, the pattern post-lockdown has shown that within 3-4 weeks maximum you've seen the active new cases going down. Unfortunately, in India the national curve has not shown this—a big reason is the state-level heterogeneity. We have slowed the virus down, but have not eradicated it.

From what you're seeing, what are some of the unique challenges that the country is facing in managing the spread?

India is very unique, of course. It has 1.34 billion people and many very large, densely populated areas so it's a very hard place to roll out social distancing interventions. For example, the two hotspots, Mumbai and Delhi, have very large slum areas where the housing conditions are very congested. Multiple people live in very small rooms, so the concept of social distancing is very, very difficult. However, (Mumbai's) Dharavi, Asia's largest slum, has been able to contain the disease by a strong strategy of centralized quarantine, temperature and symptoms check, and health care support. This shows that even when home quarantine and isolation is not feasible, there is still hope in a low-resource setting. 

Another unique challenge with India's national lockdown was that there was not enough preparedness to let the migrant workers return to their home safely with proper transportation and arrange for isolation and quarantine in their home states. One goal of a strict national lockdown is to capture a static snapshot of the population. However, in India it started mobility and the virus moved from the west to the east. Now it's in multiple states in the country.

Some eastern states were hit by a Category 4 cyclone in the middle of a pandemic. How do you do social distancing during the time of a natural disaster? On top of that, I think India is very unique in terms of its age-specific contact network structure because most of the elderly actually live with families, and so it's very hard to isolate them from the rest of the family. 

The health care system is fragile in India and many people are at high risk due to comorbidities related to COVID-19 adverse outcomes. The case-fatality rate in India has been low due to the youthful population, but as soon as the health care system gets overwhelmed like in Delhi or Mumbai, we will see death tolls rise.

Has India reached its peak? 

I think this concept of a national peak is fundamentally flawed for India, where six states contribute to more than 90% of India's cases. They have not reached their peak yet. Delhi, Maharashtra and Tamil Nadu are on the rise followed by Uttarpradesh, West Bengal, Gujarat. So there will be a cascade of statewide peaks over the summer. Other states, for example, Punjab and Kerala, have seen their first peaks. They are starting to see a bump again due to increased mobility but I am hoping they can test, contact trace and isolate those cases due to the more manageable smaller numbers and the fact that the new cases are mostly imported.

So the peak for India, according to our model, is late July and August nationally but it keeps changing based on what we see across the states each day, and there is a large uncertainty in those predictions.

What would you suggest can be done about it?

The Indian government, the public, the scientists, the policymakers, everyone has to work together to minimize the loss of life and fatalities during this time. I do not think relocking the nation is a feasible or even sensible solution at this point. The public need to manage and minimize their personal risk and think about this pandemic in a pragmatic way that does not strike panic but motivates them to adopt the best prevention strategies. 

Increasing testing and health care capacity is key in hotspots. We need to capitalize on the gains from an early lockdown by restricting our mobility to only necessary and core functions. If things get worse in terms of hospital capacity one can think of modulated/punctuated lockdowns in a localized way but the truth is that one cannot hide behind the shields of a lockdown forever. We need to play the long game and can not let the guards down. It will take collective buy in, patience, sacrifice and discipline. Whenever we come out of the lockdown, we need a plan.

In the next couple of months, the global attention is likely going to switch to India. Even as we look at the first phase of the pandemic, we're going to study what worked and what didn't work for a long time because of India's very unique context. The way that India fares is going to be an important global public health narrative. Our team will also continue this journey, tracking the pulse of the pandemic with data and models.

Do you think that the new guidelines that the government issued go far enough?

 I think the Indian government's guidelines for a phased exit strategy are quite detailed. However, implementation takes another level of planning, infrastructure and governance.  There is an app called Aarogya Setu that people are requested to download and use for symptom reporting, self-assessment and contact tracing. There are many national and state level policies in effect. In more remote areas, we need to employ grassroot-level community health workers to translate policy into action and communicate effectively to the public.

We have seen spread of misinformation almost as exponentially as the virus itself. I think that people are relying on Twitter feeds and social media and anecdotal evidence. It's tremendously important to release credible and trustworthy information and data which people can understand. I mean not only the educated but also people who have no education, who cannot read. Need to protect essential workers, household help, frontline health workers and the most vulnerable. In a low-resource setting, risk stratification and prioritization becomes even more critical.

A persistent strategy for communication and engagement with community members and socially marginalized groups is going to be very, very important right now. Leaders need to lead with empathy, efficiency and elasticity from the block to the district to the state level. The success stories inspire us in Kerala, Karnataka, Punjab, Dharavi, and I am hopeful that the people of India will defeat the dire model projections and finally bend the curve. The public has a huge role to play in public health.

COV-IND-19 Study Group's three-part series on the coronavirus in India: