An Exploration into Delhi’s COVID-19 Response Model

By Binoy Goswami

1. Putting Delhi’s COVID-19 numbers in perspective

As on May 11, 2020, Delhi had recorded the fourth highest number (6923) of total confirmed cases of COVID-19 after Maharashtra (22171), Gujarat (8195), and Tamil Nadu (7204) among the Indian States and Union Territories. All 11 districts of Delhi have been declared as ‘red zones’.¹ If one looks at the incidence of COVID-19 confirmed cases per million population, Delhi has the highest (Table 1); out of every one million people, 365 people have been tested positive for the virus.² There may be many reasons for Delhi having the highest incidence of COVID-19, some of which are discussed below.

First, the rate if testing is the highest in Delhi. For every one million people in Delhi, 4735 people have been tested as on May 10 (Table 1). In the Indian context, we have found that the number of confirmed cases and the number of tests performed have a strong positive correlation (0.70).  Going by this, the higher number of testing has helped in identifying more confirmed cases in Delhi.

Second, high population density and a higher degree of urbanization may also contribute towards a faster spread of the virus. Chatterjee and Jain (2020) find a positive association between population density, urbanization and COVID-19 related case fatality rate (CFR) in India. It is highly likely that this positive correlation will also hold true in the context of confirmed cases. As per the 2011 census, NCT (National Capital Territory) of Delhi has a population density of 11320 which is the highest in the country and 97.5 % of Delhi’s population is urban.

Third, Delhi being the national capital and one of the major arrival destinations for people travelling to India, received a sizeable number of coronavirus positive people who returned home from abroad. As the Chief Minister of Delhi has stated,³ when a considerable number of states in India had no cases of coronavirus infection, Delhi started with 1700-1800 positive cases of COVID-19, out of which 700-800 cases were infected Indians who had returned home from abroad and around 1100 cases were the fallout of a religious gathering that happened in Delhi during the beginning of the month of March.⁴

Source: https://www.COVID19india.org/ accessed on 11.5.2020. Note: CFR (Case Fatality Rate) has been calculated by the author as – [(cumulative death up to May 10/cumulative death+ cumulative recovery up to May 10)*100] (Following Ghani et al. (2005), Chatterjee and Jain (2020) have estimated CFR of COVID 19 for the major Indian states on a specific date.); AGR (Average Growth Rate) for the week 4 to 10 May 4;* these are approximate numbers as of May 10.

In addition to the above, there may be other reasons as well that can be attributed to Delhi experiencing the highest incidence of coronavirus per million population. Identifying those reasons will, however, require more rigorous and disaggregate level study, which is beyond the scope of this analysis.⁵

It is interesting to note that while Delhi has the highest incidence of confirmed cases, it had recorded relatively low CFR (3.32, Table 1).  It is understood that ages and comorbidity statuses of patients are important determinants of the CFR in the context of coronavirus infection. In Delhi, till May 3, about 68% of all the positive cases were in the age group below 50 years.⁷On the other hand, 52% of the deaths happened in the age group of 60 years and above. Further, there was comorbidity in case of over 86% of the overall deaths. Thus, the relatively younger age of virus-infected people may be one of the probable reasons for the lower CFR in Delhi.

In the remainder of the essay, I present an account of the response of the Government of Delhi while handling the emergency situation due to the spread of COVID-19.

2. Response of the Government of Delhi

The ‘5 Ts model’ of response

On April 7, the Chief Minister of Delhi presented a model of ‘5Ts’, which his government would follow to confront the challenges posed by the coronavirus pandemic. These 5Ts are, testing, tracing, treatment, teamwork, and tracking.

Testing: Inspired by the South Korean model, the Government of Delhi considers that doing large scale testing is of utmost importance.⁸ Only through large scale testing, and thereby identifying the infected persons, the spread of the disease can be contained. Delhi started with random tests in the hotspots. One could argue that not enough tests have been conducted in any states or UTs in India, given the limited resources and health infrastructure in India. However, in spite of these limitations, Delhi has done relatively better and its record of the highest number of testing for every million people is a testimony to this.

Tracing: Identifying people who have come in contact with a positive patient is an important part of the containment strategy. Though it is a painstaking job, people who came in contact with positive patients need to be identified and quarantined to break the chain of infection. The Government of Delhi and Delhi Police have worked in close co-ordination to operationalize this. As per information available, on April 7, 2020, the Delhi government had already given the phone numbers of around 28,000 people to Delhi police. This was to ensure that those people who were asked to self-quarantine were indeed staying at home. The decisions regarding sealing areas, self-quarantine and monitoring were to be based on tracing.

Treatment: This involves treating people with different intensity of infection, which requires setting up of COVID-19 Testing Centres (CTC), COVID Care Centres (CCC), COVID Health Centres (CHC) and COVID hospitals, and also the procurement of PPEs (Personal Protective Equipment), ventilators and oxygen beds.⁹ On April 7, when Delhi had around 525 active cases only, it already earmarked about 3000 beds in three government and three private hospitals specifically for treating COVID-19 patients. The Government also put a plan in place to arrange 30000 beds in phases, comprising of 8000 beds at hospitals, 12000 hotel rooms, and around 10000 beds in banquet halls and dharamshalas. It was decided that while the most serious patients with comorbidities and above 50 years of age would be kept in hospitals, patients below 50 years and with mild infection would be accommodated in hotels and dharamshalas with sufficient medical facilities. Further, efforts were also put in place to arrange 400 ventilators and 1,200 oxygen beds, which was the expected requirement when the number of patients would touch 30000.

Teamwork: Coordinated efforts of all the stakeholders are required to emerge victorious from this battle against the coronavirus. The Central Government, Delhi Government, all other state governments, opposition parties and all the agencies involved should work as a team.

Tracking: This refers to the monitoring of whether the above 4Ts have been implemented properly or not on a periodic basis, for which the head of the administration is responsible.

3. Specific measures taken by the government

Delhi had its first coronavirus positive case on March 2. The next day a meeting of the State Task Force (STF) was held wherein preparedness of the administration and actions to be taken to control COVID-19 were discussed. In fact, the decisions taken in this meeting set the stage for the fight against COVID-19 in Delhi.

The specific measures, as inferred from various government orders,¹⁰ taken by the government of Delhi to fight COVID-19 have been discussed below.

Generating public awareness:

Several agencies of the government have been assigned the tasks of sensitizing different sections of people about COVID-19, issuing general advisory and do’s and don’ts, displaying IEC (Information, Education and Communication) materials on notice boards and other prominent sites for the knowledge of public.¹¹ A few examples are as follows:

a. The Education Secretary of Government of Delhi was tasked with information dissemination among school children and teachers and to nominate a nodal teacher from each school to implement the government’s decision with regard to COVID-19.

b. District and sub-divisional magistrates were given the responsibility to sensitize the general public and residential welfare associations.

c. Delhi police, CEO of Delhi Jal Board, Delhi Metro Rail Corporation and Railways, Employees’ State Insurance Corporation (ESI), airport authority and directors of the Delhi government hospitals were tasked with sensitizing their staffs, and the general public by displaying general advisory and do’s and don’ts in places within their jurisdiction.

d. Local bodies (DMCs/Delhi Cantonment Board) were asked to do the same among children in schools under their purview.

e. Delhi Disaster Management Agency was given the task of coordinating the job of sensitizing the community.

f. The Directorate of Information and Publicity was asked to release advertisement in print and electronic media including metro panels.

Medical preparedness:

a. By March 3, the Government had assigned responsibilities for different agencies with regard to strengthening the medical preparedness to deal with COVID-19.

i. Delhi police: Moving the patients for quarantine if required.

ii. Local bodies: Activating public health department, monitoring preparedness and training of hospital and dispensary staff, and ensuring the availability of N-95 masks, PPE kits and hand-sanitizers.

iii. ESI and CGHS: Ensuring the preparedness of hospitals and dispensaries under them; procurement of masks and PPE kits.

iv. Railways: Ensuring the preparedness of railway hospitals.

v. Dean, Maulana Azad Medical College: Coordinating all medical and nursing colleges in Delhi; responsible for the training of nursing students for the control of COVID-19.

vi. NCDC/IDSP: Providing laboratory support for the testing of COVID-19 samples and technical support for the drafting of standard operating procedure (SOP).

vii. Directors/superintendents of Delhi government medical colleges: Marking of dedicated areas for treating patients with flu-like symptoms and keeping isolation areas ready as per protocol, ensuring smooth transport of laboratory samples, availability of logistics and functioning of ventilators.

b. By March 9, 27 hospitals were identified as designated centres for isolation of COVID-19 cases. All these hospitals were authorized to initiate collection of samples of COVID-19 and microbiologists of all these hospitals were to be trained by NCDC. Additionally, every district was asked to constitute at least 50 surveillance teams at field-level to carry out a house-to-house survey in the containment zones.

c. In line with the guidelines issued by the MoFHW, the Government of Delhi issued SOP for operationalizing COVID Testing Centres (CTC), COVID Isolation Centres (CIC) and COVID Health Centres (CHC) on April 16.

d. By March 20, all MSs/Directors/MDs/HoDs of government hospitals were asked to ensure with immediate effect that all equipment and machines in their hospitals were functional, additional ventilators and high-flow oxygen masks were arranged, essential medicines and consumables were available, COVID-19 patients were under supervision and could not escape, samples of suspected COVID-19 patients were sent to designated centres for testing, separate flu corner was functional and isolation protocols were followed, all examination/evaluation works and non-essential elective surgery were suspended for the time being. Further, government hospitals were allowed to recruit additional manpower up to 25 % of sanctioned strength on a temporary basis. It was decided that the senior doctors, clinical and non-clinical, would be assigned duties; leave of medical and paramedical and nursing staff would be cancelled; and, all interns and postgraduate students of certain colleges and nursing students of all colleges would be kept on standby.

e. An order was issued on April 2, whereby individual hospitals/CPA were allowed to immediately procure PPE kits from local manufacturers at market rate.

Containing the spread of the virus:

• Local bodies were tasked to carry out surveillance of hotels as per guidelines; biometric attendance in all Delhi government offices was withheld; ESI and CGHS were asked to do the screening of patients at dispensaries and hospitals; airport authority was directed to strengthen the surveillance system at airports and share the details of passengers on a daily basis. Doctors and paramedical staff from Delhi government were deputed at Airport Health Organization (APHO) for the screening of passengers.
• MHO of three DMCs started screening hotels/lodges for tourists coming from COVID-19 affected countries, and the daily report was shared with district surveillance officers. It was also decided that any person coming back from COVID-19 affected area/country must self-report.
• On March 12, the Government of Delhi notified the Delhi Epidemic Diseases, COVID-19, Regulations 2020, and subsequently invoking these regulations ordered that all classes of all types of schools, colleges, ITls, Polytechnics and the operations of all cinema halls, public swimming pools in NCT of Delhi would be suspended till March 31. Thereafter, Delhi Epidemic Diseases, COVID-19, Regulations 2020 has been invoked many times. These regulations also put in place the modalities for earmarking containment zones.
• An order-dated 13.3.2020 prohibited all sports gathering/conferences/seminars beyond 200 people in NCT of Delhi. The number of people allowed for such gathering was further reduced to 50 persons on March 16 and 20 on March 19.
• On March 16, the operations of all gymnasiums, SPA, discotheques, theatres in NCT of Delhi were suspended till March 31. Further, it was directed that all shopping malls should be disinfected daily and shall also make provisions of availability of an ample number of hand sanitizers for visitors at the main entrance and at individual shops.
• Through an order dated March 19, all restaurants were asked to discontinue sitting arrangements and all sports complexes were asked to remain closed till March 31.
• All foreign returned persons and their contacts were asked to remain under home quarantine for 14 days through an order issued on March 22. The order also specified that failure to remain under home quarantine would attract punishment.
• Before the national lockdown was announced, the order of the Government of NCT of Delhi Delhi dated March 22, notified a lockdown in the whole of territorial jurisdiction of NCT of Delhi from 06.00 on March 23 to midnight of March 31. Only essential services with the obligation of maintaining social distancing were allowed. Any congregation of more than 5 persons was strictly prohibited and made punishable as per law. All the relevant agencies under the government were asked to ensure the implementation of the lockdown.
• An order, dated April 24, asked all CDMOs to provide medical facilities and screening for COVID-19 symptoms among the people in temporary shelters for poor/homeless and migrants workers.
• The order dated April 8, made masks in public places a must.

Implementing the lockdown

It is evident that the Government of NCT of Delhi got into actions as soon as the first case of COVID-19 positive in Delhi was reported. Many measures were taken to contain the spread of the disease even before the national lockdown. In fact, the government order suggests, as discussed above, the Government of NCT of Delhi issued an order announcing a lockdown within its jurisdiction even before the national lockdown was announced, though for a much shorter period. During the first two phases of the national lockdown, Government of Delhi did not allow any relaxation beyond what was suggested in the guidelines of the Union Home Ministry. Even during the third phase, the government allowed only those relaxations, which had been approved by the Central Government.¹²

Managing the economic fallout of the lockdown

The economic impacts of the lockdown have been very harsh on the people employed in the informal sector, and those who work as casual workers in the formal sector. The plight of the migrant workers, who got trapped due to sealing of inter-state borders during the lockdown, has already been documented in print and electronic media. The Government of Delhi has put in place relief measurers for such people, (i) setting up of temporary relief centres and hunger relief centres, and (ii) provision of temporary ration cards. Some other measures in this regard include, (i) one-time financial assistance of Rs 5000/- to the holder of PSV (Public Service Vehicle) badge with a valid driving license to be credited to their Aadhar linked bank account, and (ii) provision of paid leave by employers to all the people who are advised to be in home quarantine.

Coordination with local authorities/Delhi government:

One would appreciate the fact that the coordinated effort of all the stakeholders is a must to handle a pandemic like the current one. Nodal persons from different agencies have been identified for coordinating with local authorities and Delhi government. For example, directors of the Delhi government hospitals have been asked to coordinate with local authorities. Before a decision to close the schools was taken, a nodal teacher from each school was selected to implement the government’s decision with regards to COVID-19. The same can be said in case of many other agencies also.

Management of information on COVID-19:

To avoid panic among the public and ensure timely and appropriate action, it is important to manage information about the status of the spread of the disease and government’s various decisions in a transparent and comprehensible manner. Some of the measures taken in this regard are:

1. Launch of a dedicated WhatsApp COVID-19 helpline number.
2. Director EMR put in charge of providing all the updated status, protocols, guidelines and a list of essential contacts for the containment of COVID-19.
3. A COVID app has been created wherein all government/private COVID testing labs and hospitals need to fill the requisite data to ensure proper follow-up of COVID-19 cases.
4. All labs have been directed to send a report of every first test that is positive and that of every patient undergoing a repeat test to Integrated Disease Surveillance Program, Delhi for ensuring immediate monitoring of all cases.
5. In order to avoid the spread of rumours or unauthenticated information regarding COVID-19, an order dated March 12 was issued which prevented any person/institution/organization from using any print or electronic media for information regarding COVID-19 without prior permission of the Department of Health & Family Welfare, Govt. of NCT of Delhi.
6. Compliance of the order of the Delhi High Court dated May 4, which directs the government to upload the details of the sample collected to test COVID-19 on a daily basis on its website.

It transpires from the discussion above that the Government of Delhi has been pro-active in dealing with the COVID-19 pandemic. It has monitored the situation continuously and responded to it as per the need of the time. While formulating its response strategy, all stakeholders and their positions within the response model have been clearly identified and the responsibilities assigned to them have been unambiguously stated. Channels of communications among all the stakeholders and powers or agencies delegated to various executioners of government plans have been aptly established. Despite putting in place a well-meant response model, the spread of COVID-19 in Delhi is, however, far from being under control (see Figure 1).

On April 30, the total number of confirmed cases in Delhi was 3515, which increased by 3027 to 6542 on May 9. Notwithstanding the fact that more number of confirmed cases may have been reported due to the increase in the number of testing as discussed above, the spike in confirmed cases in the last couple of days, however, raises questions about the efficacy of implementation of response plans, including that of motivating the public to follow the lockdown. Additionally, the government has come under criticism for allegedly underreporting the number of deaths related to COVID-19.¹³ One would expect that Government of Delhi report all the data related to COVID-19 cases transparently so that not only does the government’s credibility in dealing with the crisis is ensured among the citizens but also the seriousness of the situation is not lost on the general public.

4. Way Forward

Given the recent spike in confirmed cases, as can be inferred from Figure 1, the Government of NCT of Delhi will have to remain watchful in the coming days. Once the lockdown is lifted, the number of confirmed cases may increase with the increased use of public spaces. Government has to be more cautious in allowing relaxations. For instance, a few days back when the government allowed the opening of liquor shops, a huge number of people queued up without adhering to social distancing. Though the next day, the government introduced a system of e-coupon, the damage might have already happened.

Testing more people, isolating confirmed cases and subsequently treating them is probably the most effective containment strategy in case of a pandemic, especially in the absence of a vaccine. The government has to increase the scale of testing. In order to do mass testing, the government may consider introducing more mobile testing booths and allowing more private labs to conduct COVID-19 test. Further, the government must ensure availability of other logistics like PPE kits, ventilators and oxygen beds etc., to deal with a situation when more positive cases are reported once the lockdown is over.

Following social distancing in public spaces and adhering to the norms of personal and public hygiene will continue to remain one of the most important strategies in containing the spread of the virus. A lot more can be done in this regard. As of now, only the law implementing agencies are trying to ensure that social distancing measures are followed. However, these are constrained by the shortage of manpower to monitor all places and at all times. The government must sufficiently empower the community-level institutions, such as residence welfare associations to implement social distancing measures. Delhi’s high population density makes maintaining of social distancing more challenging, and without the help of community-level institution, such measures cannot be effective. One of the reasons why more cases have been reported in Delhi in the last couple of days despite the lockdown is probably because social distancing guidelines may not have been followed by the general public to the extent necessary.

Above all, the government must remain vigilant and take stock of the situation on a daily basis. It should stand ready to intervene with policy measures in accordance with the manner and nature in which the ground reality evolves. Since a complete lockdown for an indefinite time period is not sustainable and therefore, will have to be relaxed soon, the need is for the government to be on a constant watch; ensuring it gets real-time reports from the ground; and, being prepared for a timely response.

AUTHOR

Binoy Goswami, Senior Assistant Professor, South Asian University, New Delhi

Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation. 

REFERENCES

Chatterjee, Chitra and R Jain (2020): Is Covid-19 equally deadly across all states? available at https://www.ideasforindia.in/topics/macroeconomics/is-covid-19-equally-deadly-across-all-states-a-preliminary-examination.html accessed on 1.5.2020

Ghani, AC, CA Donnelly, DR Cox, JT Griffin, C Fraser, TH Lam, LM Ho, WS Chan, RM Anderson, AJ Hedley and GM Leung (2005): “Methods for Estimating the Case Fatality Ratio for a Novel, Emerging Infectious Disease”, American Journal of Epidemiology, 162(5):479-486.