Responding to the Pandemic: The Gujarat Model

By Keshab Das and Hastimal Sagara

Introduction  

The western Indian state of Gujarat has been an economically prosperous state all along and known for its commercialism, business acumen and industrial investment.  Occupying the fourth position in terms of gross state domestic product (as in 2016-17) Gujarat has a strong network of physical infrastructure including all-weather roads, airports, electricity coverage and, of late, special economic zones and special investment regions. The state enjoys political stability with the BJP government in power since over a quarter of a century now.  An additional advantage the state has relates to the existence of a wide range of active civil society organisations who have always risen to the occasion in taking on responsibilities, including supporting the local and state governments, during times of socio-economic crises.  Often cited as the Gujarat Model of development – for quality infrastructure and being a haven for jobs – in recent decades, this state also had been the site of large scale disasters, notably, the plague epidemic (1994), a massive earthquake (2001) and widespread communal violence (2002).  Responding to or tackling these events, inter alia, has deeply influenced the governance framework of the state.  The health sector, particularly, has grown rapidly during the post reforms period with a large presence of the private capital in healthcare, medical education and pharmaceuticals.

Going by the aforesaid, it was reasonable to deduce that the unprecedented COVID-19 pandemic was going to be handled by Gujarat in a manner that would serve an example to several Indian states.  However, quite contrary to this expectation, as the pandemic has been unfolding into its fifth month in India, it is becoming clear that Gujarat’s predicament in containing the spread and deaths has been massive. The state stands nowhere close to the efforts and achievement of several other Indian states neither as prosperous nor having as comparable extensive, high-end healthcare endowments.  How has Gujarat responded to the pandemic thus far is the central concern of this short paper.  The materials referred to in this article are government statistics/announcements, media reports and views expressed by various stakeholders all available in the public domain.

Implosion of an impending crisis

Following the outbreak of COVID-19 pandemic in Wuhan that alarmed the globe, the first index case in India was reported from Kerala on January 30, 2020.  While panic buttons had been pressed by both the Central Government and most state governments had been on an alert mode, the Gujarat government remained unperturbed.  In fact, the state government under a directive from the Centre remained busy for over a month or more in arranging and celebrating the huge ‘Namaste Trump’ event on February 24, 2020, in which about over 1,00,000 people (including foreigners and domestic visitors who flew in and out of the city) attended the mega event at a stadium in Ahmedabad.  As the State Congress President observed, ‘In January itself, WHO clearly said that the coronavirus spreads from one person to another. It had asked all the countries to refrain from organising large gatherings. Despite such warning, ‘Namaste Trump’ was planned … and permission was also granted by the Gujarat government.’¹ Several media reports suggested that crucial time was ‘wasted’ and corona-preventive measures were thrown to the winds.

There were several reports of passengers moving out of Ahmedabad International Airport and people travelling within the state by road or railways and driving away to their destinations without any medical check-ups or testing at any stage.² With every passing day, cases rose fast in states like Maharashtra, Kerala and Delhi and even when media reports stressed the need to build up a strong inventory of medical apparatus in Gujarat to face the impending health crisis, the state remained complacent. This may have been because no case was reported in the state in the initial weeks.

The first two positive cases in Gujarat were reported by March 19, 2020, one each from Rajkot and Surat.  Then, as there were not many coronavirus cases reported almost until April 14, 2020, there was no active preparation to deal with the disease just in case it spread.  For this entire two-and-a-half-month period (starting January 30, 2020) hardly any precautions were taken to screen passengers entering the state, enforcing social distancing measures, and rarely anyone wore a mask.  In fact, before the total lockdown was in place, when the 14-hour (from 7 am to 9 pm) so-called ‘Janata Curfew’ was observed country-wide on March 22, 2020, large crowds spilled into the streets across the state in an exalted state of celebration. They were not stopped and no precaution was taken by the state to prevent this dangerous public behaviour.³ As the state remained, or it so seemed, ‘untouched’ by this deadly virus well into the total lockdown days and states like Maharashtra, Delhi, Kerala, Haryana and Rajasthan were reeling under the shooting cases (and deaths), there was little progress in the state’s preparedness, at least in terms of public health measures of broad-basing awareness campaigns or readying government hospitals to face the eventuality.⁴

On April 15, like a bolt from the blue for the state government, the corona-positive cases in Gujarat started to spike.  From a minuscule base, it jumped to the second position (after Maharashtra) in the country and in just over a month, by May 18, 2020, the total number of positive cases had crossed the 10,000 mark. The death rate in Gujarat was very high.  Table 1 presents statistics on total positive cases in some of the highly affected states.  While Gujarat has the third-highest number of positive cases, the death rate is almost double that of the national average and second only to West Bengal.

Table 1: Status of COVID-19 Cases in Highly Affected Indian States

Source: https://www.mygov.in/corona-data/covid19-statewise-status (Accessed May 26, 2020; 02:00 am)
Note:  Figures in parentheses are percentages to the total number of positive cases. 

Following a mild beginning, the abrupt shooting up of cases in Gujarat, especially since April 15, 2020 (Figure 1).  More worrying was the high percentage of deaths (at times hovering around 8-9 percent) during the initial days (during March 22, 2020, and April 8, 2020) and gradually settling at around 6 percent in subsequent days (Figure 2).

Figure 1: COVID-19 Positive Cases in Gujarat by the Day (March 18 – 25, 2020)

Source: Drawn on the basis of data obtained from Worldometers and Wikipedia (Accessed May 26, 2020)

The disturbing aspect of this rapid increase in cases, as shown in Table 2, was that just four districts – Ahmedabad, Surat, Vadodara and Gandhinagar – accounted for 90 percent of all cases in the state.  However, the unusually high number (over 73 percent) of cases was concentrated in Gujarat’s numero uno urban district Ahmedabad – the ‘healthcare hub’ of India.  The death rate was also high in Ahmedabad. As media reports started flooding in, it was clear that the state in general, and Ahmedabad city, in particular, was caught unawares, to deal with this huge challenge.

Table 2: Situation of COVID-19 Cases in Gujarat (as on May 26, 2020)

Source: https://www.covid19india.org/ (Accessed May 26, 2020; 2:21am)
Notes: Figures in parentheses in the second column are percentages to the respective column total.
Figures in parentheses in the last column are percentages to the respective confirmed positive cases given in the second column.

As on May 23, 2020, for every 1 million people in Gujarat, 2540 people were tested and 195 had tested positive for the virus.⁵ Moreover, for every 100 confirmed cases, 50 are currently infected and 44 have recovered from the virus while 6 out of 100 positive cases ended in death due to COVID-19. In the last one week, the number of new infections has grown by an average of 3 percent by the day. The Saurashtra region of Gujarat has remained the least affected thus far, where precautions were taken, for instance, use of masks was made mandatory, marriage functions/processions were permitted with strict adherence to social distancing, and so on.⁶

In keeping with the Central Government’s directives, a plethora of lockdown measures has been adhered to by the Government of Gujarat.  The state government has also made several auxiliary announcements during these four phases of the lockdown which are included in Table 3.

Table 3:  Status of COVID-19 Cases and Government Announcements in Gujarat during Lockdowns 1-4

Source: Compiled by the authors based on media reports and Government of Gujarat materials.

State and stakeholder response

How has the response to the crisis by the state and other stakeholders been?  An attempt has been made to summarise responses and events through the following four broad typologies.

Bureaucracy and Police to the fore
All through, the state administration remained confined to its top-line bureaucracy and there was hardly any public engagement on the disease by ministers of health, urban affairs, child and women development, industries, rural development, social welfare and employment, to mention the most relevant ones.  As it unfolded, at the levels of the districts, small and medium towns and rural areas, neither the elected representatives of local institutions (the Gram Panchayats, in particular) nor the widespread and established civil society organisations had any noteworthy role to play either in creating awareness about the pandemic, helping local quarantine centres or in keeping a vigil on and registering incoming persons to the local places and so on.  Instead, as pointed out by a local NGO, police were deployed at these local levels severely undermining the relevance and propriety of local representatives.⁷

During the four phases of lockdown (Table 3), the state government notifications on the lockdown permitted functioning of shops selling essentials but prohibited sale of pan masala, cigarettes, bidis and other tobacco products. All gatherings of people, including schools, colleges, universities, coaching institutes, yoga and dance tutorials were to remain closed. The state government provided corona-related helpline numbers, 104 for fever or COVID-19 related information, 108 for health-related emergencies, 9013151515 Whatsapp Chatbox for COVID-19 related queries, 1075 or +911123978046 as a national helpline. Select private hospitals were allowed both testing for coronavirus and treatment of COVID-19 patients. Women with pregnancy, people over the age of 65 and children below the age of 10 were not permitted to step out during the third lockdown, except for medical emergencies.

In order to stop local transmission, the government adopted a new strategy for seven days starting on May 7, 2020, that permitted only milk parlours and medical stores to operate in Ahmedabad city. Within minutes of the announcement of this much stricter lockdown, people queued up in front of grocery shops, flour mills, vegetable shops, bakeries, etc. to buy essentials at least for the said period.

Interestingly, for the first time since the announcement of the lockdown, the government decided to collaborate with elected members of the municipal corporation, NGOs, youth organizations. The Chief Minister of Gujarat declared a week-long campaign (May 21-27, 2020) labelled ‘Hu Pan Corona Warrior’ (I too am a corona warrior) to spread awareness about measures to combat the virus among the general public.⁸ The Government of Gujarat announced Rs 5000 crore ‘Atma Nirbhar Gujarat Sahay Yojana’ for about 10 lakh small business units or self-employed individuals with an advance of Rs 1 lakh from cooperative banks and credit societies at two per cent interest rate and other benefits.⁹ On May 18, 2020, the government announced the sale of triple-layer masks and N95 masks at Rs 5 and Rs 65, respectively, at 2000 stores of Amul, a Gujarat based milk cooperative.¹⁰

Medical preparedness and challenges
With widespread privatisation of the healthcare sector, Gujarat has not built up a robust public health system at the sub-district and village levels.  A recent report observed that ‘…despite all its efforts, Gujarat still has certain hurdles to cross. Shortage of trained manpower, increasing real estate and electricity costs, lack of fast track implementation of announced initiatives and standard of governance in the hospitals are some of the challenges…for both government and private players in Gujarat.’¹¹ Shortage of specialists and lack of facilities in rural and taluka-level government hospitals ultimately resulting in increased healthcare-related expenses have been pointed out by experts.¹²

In the context of COVID-19, the state administration had identified three factors responsible for the rapid rise in cases in the state, namely, delays in admitting affected persons in hospitals due to stigma, co-morbidity and certain groups of people identified as ‘super-spreaders’.  However, there were issues about medical preparedness, especially inadequate testing facilities. The Ahmedabad Municipal Corporation (AMC) managed well-known VS Hospitals’ space, infrastructure and expertise have remained completely unused during the lockdown period.  On the contrary, a relatively newly built multi-storeyed Sardar Vallabhbhai Patel Institute of Medical Sciences & Research (SVPIMSR or, SVP hospital) has taken the centre stage in the treatment of COVID-19 in Ahmedabad. About 100 resident doctors and paramedical staff attending COVID-19 cases at the SVP hospital went on a flash strike complaining about non-issuance of respirators (masks) and Personal Protective Equipment (PPE) in addition to other problems. The AMC authorities, however, maintained that they had been issued the required safety kits and there was adequate stock of the same.¹³  The AMC made it mandatory for owners and staff of shops and supermarkets to get their medical screening done by approaching their respective wards and obtain ‘health screening cards’ based on test results.

There were several reports in the media around mid-April portending that COVID-19 patients were ‘segregated’ at the Ahmedabad Civil Hospital on religious grounds.¹⁴  While the state government rebuffed the ‘allegation’ and the hospital staff remained ‘tight-lipped’, ‘insiders said the decision was taken after a large number of cases were reported from a cluster of a religious gathering in Delhi and their contacts in minority-dominated pockets of the city’.¹⁵

To add to the rigidity of over-centralisation by a few bureaucrats who also were changed due to unsatisfactory performance, the new in-charge bureaucrat, on May 6, 2020, passed an order asking all private healthcare units and nursing homes in Ahmedabad city to reopen their facilities failing which they would lose their licenses.  However, the following day the same officer announced a strict lockdown which implied the private healthcare services would be penalised if they started their units.  Already upset over being side-lined by the state in the fight against COVID-19, the two major bodies – Ahmedabad Hospitals and Nursing Homes Association (AHNHA) and the Ahmedabad Medical Association (AMA) – denounced the ‘coercive methods’ and ‘insulting treatment’ by the AMC and the city police personnel who blocked/restricted their mobility and did not take steps to ensure the safety of their healthcare staff and patients.

The inept handling of the medical equipment and essentials for doctors, nurses and a range of support service providers was another aspect of Gujarat’s poor preparedness of the COVID-19 crisis.  It was reported that there was a severe shortage of medical accessories to deal with the fast-rising cases in the state.  Representatives of both AHNHA and AMA had expressed concern about the insufficiency of ‘affordable and good quality’ protective gear, like face masks and PPE for healthcare workers.  There were reports suggesting that these essential products were being manufactured by a few ‘fly by night companies’. ‘As a consequence of this, the government ended up being in confrontation with private healthcare service providers at a time when it wanted them to share some of the load on public hospitals which have been filled with coronavirus patients as well as those seeking treatment for other ailments.’¹⁶ There were reports of improper disposal of used PPEs by both staff and family members involved in the cremation or last rites of those dead due to the COVID-19 infection.  The used PPEs were found carried by stray dogs heightening the fear of spreading infection elsewhere in the city.¹⁷

There were cases of breach of privacy rights in Gujarat when vital information about corona positive patients was put in the public domain. For instance, the government would place a list of corona positive patients on its website with their name, address, mobile number and the hospital where their treatment was going on. The medical team would put a ‘quarantined’ stamp on every patient’s hand for the purpose of easy identification and to prevent him/her from mixing with others. Further, the Aarogya Setu mobile application helped track the movement of the person. Once somebody tested positive, their entire family were ‘home quarantined’ with a sticker put in the front of the house. Arguably, the purpose was to keep people better informed, but such moves may also have stigmatised those infected.

The public healthcare system’s preparedness was summed up in an embarrassing new report on May 20, 2020, that stated, ‘Asia’s largest, Civil Hospital has earned a rather stoic sobriquet – Ahmedabad’s COVID-19 graveyard. This is because more people with coronavirus have left the hospital in a bag than walked out surviving the pandemic’.¹⁸ At this hospital, junior doctors and interns complained about their senior doctors remaining absent from duty, particularly when skilful procedures were to be carried out by qualified doctors.¹⁹  Further, on May 24, the Indian Express carried a report that stated, ‘The Gujarat High Court came down heavily on the state government for trying to “artificially control” the COVID situation in the state and called the Civil Hospital in Ahmedabad, the main government COVID facility in the state, “as good as a dungeon, maybe even worse”.’²⁰

A major controversy emerged when it was reported that the Gujarat Government, without any mandatory licence from the Drug Controller General of India and formation of an ethical committee to monitor, as per the Medical Devices Rules, 2017, had permitted the use of ventilators (‘Dhaman-1’ produced by a Rajkot based firm Jyoti CNC) at hospitals across the state in treating COVID-19 patients and this allegedly caused deaths.²¹ However, the government rejected this argument and claimed that Dhaman-1 was a credible product and did not require the said license.²²  Interestingly, authorities at the Civil Hospital in Ahmedabad, stated that Dhaman-1 installed at government facilities were not high-end machines and were not giving the ‘desired results’ on COVID-19 patients, and it, therefore, requested for supplying new high-end ICU ventilators from the Centre.²³

Distancing and disdaining the marginalised
During the prolonged lockdown period, certain sections of the society were deeply inconvenienced as the ‘territorial’ lockdown nullified possibilities of what was termed a ‘functional’ lockdown by Morris (2020).²⁴ For instance, farmers faced difficulties in selling their Rabi crop particularly wheat, gram and cumin in the Agriculture Produce Market Committee (APMC) markets due to lack of clarity in the formal communication between different stakeholders of the APMCs during the first two lockdowns.²⁵ Moreover, the non-availability of machines and agricultural labourers for harvesting wheat, tomatoes, potatoes and cabbage led to farmers losing vital time to cart their products to APMCs. The government’s strict guidelines for commercial vehicles disrupted, though temporarily, the supply chain of farm products between villages and mandis.²⁶ The retail prices of vegetables in Ahmedabad doubled, however, farmers ended up selling their products at low prices out of compulsion.²⁷ These developments caused farmers, particularly the small ones, to earn 60-70 percent less incomes on a daily basis.³⁰ Nearly 2,000 suspected super-spreaders were screened in two days after the AMC ordered the closure of all shops, except milk and medicines, in the city for a week from May 7, 2020.³¹ The government, on May 16, 2020, found 709 super-spreaders as corona positive.³² This approach could potentially stigmatise the providers of basic services at the margins of the occupation-income chain and almost entirely in the informal domain and compromised their dignity and livelihoods.  The names and other personal details as location and occupation of the so-called super-spreaders were in circulation on social media.

Migrant workers as expendables
One of the worst-hit groups in the COVID-19 spread in Gujarat has certainly been the massive number of migrant workers toiling mainly in the textiles, engineering, chemicals, diamond polishing, salt works and several other manufacturing and services sectors.  In the absence of any official statistics on the total number of migrant workers in the state, industry estimates put it at about 3 million working at various industrial sites, hailing mostly from Odisha, Uttar Pradesh, Bihar, Jharkhand and Madhya Pradesh.³³ Despite no formal recognition, these workers have been making the around 4,00,000 micro, small and medium enterprises (MSMEs) and related activities function smoothly.  When the COVID-19 cases started to rise, these enterprises, industrial clusters and workplaces (mostly located in Ahmedabad, Surat, Vadodara, Rajkot, Bharuch, Jamnagar, Bhavnagar and Valsad) pulled their shutters down with disastrous consequences for these migrant workers.  They lost jobs (however temporary, casual or precarious), wages (however low) and means to return to their homes thousands of kilometres away from their work areas in Gujarat.  Little attention was paid to these teeming miserable workers and their families either by the enterprises or the state in terms of providing healthcare, food or money to survive.  Poverty and overcrowding led to poor or no adherence to social distancing norms and masks were hardly worn.  Despite the Gujarat government’s order to pay salaries to workers during lockdown period, lakhs of diamond artisans in Surat, as claimed by Diamond Workers Union (Gujarat), have not been paid their wages by their employers.³⁴

Notwithstanding statements from both the state and central governments of paying travel fare to migrant workers, the stranded workers ended up paying fare for their journey.³⁵ There were instances of clashes between these frustrated and hungry workers and the administration (read, police). Clashes between migrant workers and police at a few places in Gujarat including Surat³⁶ and Ahmedabad³⁷ signalled desperate efforts of the people forcefully contained at places that were arguably insufficient, unhygienic and unsafe for more than one reason.  There was a case in Jetpur where an NGO rescued a group of 34 migrant child workers kept in confinement by two saree processing units. These children were from Bihar and Uttar Pradesh and had not been paid wages before the lockdown was announced.³⁸

Even when the Shramik (labour) Trains started on May 6, 2020, thousands of workers remained stranded at railway stations in Surat and Ahmedabad as there was no space nor could many manage formal passes to board the trains.  Some states (like Odisha, Madhya Pradesh and Uttar Pradesh) also arranged buses in collaboration with the Government of Gujarat to take the workers to their respective states. The government claimed to have sent about 10.75 lakh migrant workers – highest by any state in the country – by 750 special trains to different states.³⁹  However, mismanagement by the government in executing migrant workers’ travel plans to their home states has also been reported.⁴⁰

The urban workers who could manage to travel back to their villages are not expected to report back to work, at least, in the short to medium term ahead.  Due to this, the ceramic, construction, engineering tools and diamond industries are likely to face an immediate shortage of over 50 percent of workers who come from outside Gujarat.⁴¹

Concluding observations: Inclusive governance is the way forward

The massive spike in the total number of COVID-19 positive cases in Gujarat (which has been sharing either second or third position in the country, since mid-April) has been a cause of huge concern to the state government.  Despite efforts, the fatality rate in the state has remained disturbingly high.  It is obvious that there is need for much greater coordinated action and support, especially, for those who are poor, unprotected and sufferers of pre-existing vulnerabilities.  There have been sustained efforts by a few the civil society organisations (for instance, ANANDI, Centre for Social Justice and Cohesion Foundation) in certain locations to provide masks, health kits and basic groceries.

The state government could collaborate with the large grassroots-level organisations and local-level institutions at the village and sub-district level to benefit from a broad-based decentralised governance system to contain further spread of the virus.  It would be useful to learn from a few other states, particularly, two of the relatively less prosperous (in terms of GSDP) states – Odisha and Kerala.  Often battered by natural disasters and with a large workforce working in other states or countries for low-paying jobs, these two states have achieved enormously from a decentralised approach to the pandemic (see, for instance, Isaac and Sadanandan, 2020 for Kerala and Garikipati, 2020 for Odisha).⁴²

Inclusive governance remains the only effective way forward in a democracy faced with the public health challenge of COVID-19.  Greater consultation with multiple stakeholders, stringent healthcare and preventive practices, broad-basing quality public health systems and an empathetic approach to the vulnerable or less-fortunate would see Gujarat through the crisis with confidence.

AUTHORS

Keshab Das, Professor, Gujarat Institute of Development Research, Ahmedabad
Hastimal Sagara, Assistant Professor, GLS University, Ahmedabad
Article submitted on May 26, 2020

Acknowledgements: The authors would like to thank Rudra Narayan Mishra for insightful observations on an earlier draft.

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.