India's COVID-19 lockdown is among the strictest in the world but has yet to slow the spread

Shortly after extending what was already one of the strictestCOVID-19 lockdowns by almost another three weeks, Indian Prime Minister Narendra Modi assured those watching his televised addressthis week that "the country is in a very well-managed position."

The situation on the ground, however, suggests otherwise: While proportional to its population of 1.38 billion, India's COVID-19 caseload is small, it's been rising despite the lockdown and hassurpassed 16,000, with 2,154 new cases reported Saturday, the highest increase in a single day.

There had alreadybeenreports of hunger and distress among the poor, who have been hit hardest by the lockdown, and news that the 21-day countrywide shutdownwould be extended by another 19 daysto May 3 sparked further chaos.

Hundreds of migrantworkers angry at being locked downwith littleaccess to daily essentials and no income protestedinthe streets of Mumbai and Surat, a textile manufacturing hub in western India,demanding authorities transport them back to their villages.

Restrictions on movementhave beenstrictly enforced by police and includethe shutdown of passenger trains, buses andall domestic and international flights, as well as schools and social and religious institutions.

The government has allowed "select, necessary activities" to resume in areas that are not COVID-19 "hotspots" as of April 20 in addition to those already deemed essential. Permitted activities now include agriculture, fisheries, banking, a rural work-for-relief program and some construction, industry and manufacturing.

Government promises more relief

India has been underlockdown since March 24. At 8 p.m. that night, Modi announced on TV that in four hours, he would be halting allactivity in the entire country to prevent the spread of the coronavirus.

"If you do not take these 21 days seriously, then the country will go back by 21 years," he warned.

But absent any advance notice orconsultation with state governments and with only limited financial aid and food rations for the most vulnerable,the announcement sparked despair among India's millions of workers, especially those known in India asdaily wagers.

These are workers who live practically day to day, employed on construction sites, in small and medium manufacturing units and cottage industries, andin hotels andhomes.

Much of the labour force in India's cities is made up of interstate economicmigrants from villages around the country (at least 45 million of them, according to the 2011 Census), and astransportation and their means of employmentground to a halt, a large number were left with no choice but to walk hundreds of kilometres back to theirvillages in a desperate bid for survival.

Researchers have compiled cases of almost 200 Indians who have died as a result of lockdown-related distress, and social media is replete with SOS calls and cellphone videos from labourers stuckinside their tenements or cramped work sites, which double as accommodation for some.

The government's relief package, which includes food, gasand cash for poorhouseholds and health insurance for medical staff,has been criticized by some as too modest, at about 0.8 per cent of GDP,excluding millionsof those who need it.Finance MinisterNirmala Sitharamansaid on Friday additionalassistance would be announced in the coming days.

Is it working?

The lockdown has pushed the already sagging Indian economy into further decline, with the Centre for Monitoring the Indian Economy, a Mumbai-based think-tank, estimating that unemployment shot up from less than seven per cent in mid-March to more than 23 per cent in the first week of April.

Barclays estimated the cost to the economy would be$234.4 billionUS and zero per cent GDP growth for 2020.

Meanwhile, the public health benefits remain unclear. India has not "flattened the curve" in the past three and a half weeks, with cases rising from around 600to more than 16,000 in that time.

The number of new casescontinues to go up, as does the number of deaths, which rose from13 on March 25 to more than 520 currently.

While over half the cases are in thecities of Delhi, Mumbai, Pune, Indore and Bhopal, testing has shown that COVID-19 is present in almost all of India's 28 states and eight union territories.

"The three-week lockdown was supposed to buy the government time to ramp up testing, increase surveillance and contact tracing, acquire PPE (personal protective equipment) kits in requisite numbers for frontline workers, train health personnel, prepare hospitals to receive COVID-19 patients, and draw up a comprehensive plan for controlling the spread of the virus," said Anant Bhan, a researcher in global health, bioethics and health policy.

"There have been pockets of containment, but there is no indication that authorities have used this three-week window to address the big picture."

The Ministry of Health and the Indian Council of Medical Research (ICMR), which has been overseeing testing protocols and pandemic-related policy, did not respond to questions from CBC News.

Slow to respond

The first COVID-19 case was reported in India on Jan. 30 in a student who returned to her home in Kerala from Wuhan, China, butas late as March 13, a day after India's first coronavirus death and two days after the WHO declared a pandemic,the government said the virus was not ahealth emergency.

Eleven days later, as deaths rose in parts of Europe and North America, Modi announced he was locking down the country.

"It was like taking a sledgehammer to the problem, with no clear explanation,plan or a strategy to exit," said Vikram Patel, professor for global health at Harvard Medical School, who is currently under lockdown in the tiny western Indian state of Goa.

"These three weeks have been completely wasted because in the absence of a systematic testing protocol across the nation, we do not have an understanding of the spread and we have no way of evaluating the lockdown."

Nevertheless, as cases rise in the world's most densely populated country, a lockdown continues to be the favoured tool for federal and state governments.

Lockdown preferred approach in states

Aday beforeModi's announcement, Maharashtra, the state with the largest number of cases, said it wouldextend the lockdown until April 30 since "there has been no reduction in cases."

Maharashtra has reported more than 3,600 cases so far, including more than 2,100 in Mumbai, a densely packed metropolis and the country's financial capital.

The eastern Indian state of Odisha, an overwhelmingly rural region that has reported just 60 cases and one death, has adopted the same approach, announcing a similar extension last week.

"The one-size-fit-all lockdown has brought untold misery and suffering to millions of farmers, migrant labourers, daily wagers and business owners," opposition MP Rahul Gandhi tweeted a day before Modiextended the lockdwon.

"It needs a 'smart' upgrade, using mass testing to isolate virus hotspots and allowing businesses in other areas to gradually reopen."

The government's plan to allow some parts of the economy toreopenin areas without COVID-19 outbreaksstarting Monday is an attempt to do that.

Limited testing

The government hasdone a good job of raising public awareness ofCOVID-19, says Partho Sarothi Ray, a molecular biologist at the Indian Institute of Science Education and Research Kolkata, but has been slow to rampup testing.

About386,000 people have been tested in India so far, the ICMR said Sunday (with ratesvaryingwidely among states). That is about 280 tests for every million people among the lowest rates in the world.

The government has set the price of the test at 4,500 rupees (around $82) for all but the poor who have enrolled in a government health insurance scheme.

"4,500 rupees is expensive," said Ray. "And the test need not cost more than 800 rupees. Given there is a demand globally for testing kits, we also need to develop our own indigenous testing capacity."

On Friday, the southern Indian state of Karnataka cut the price by half to 2,250 rupees.

An order for 650,000 test kits placed in late March by Indian authorities with China was finally dispatched on Thursday, according to Indian Ambassador to China Vikram Misri.

Earlier this week, Dr. R.R. Gangakhedkar of the ICMR said the country had enoughkits "for six weeks" but did not specify how many.

"We have issued detailed protocols for who should get tested," he said at a briefing Tuesday."I cannot say why more people are not getting tested."

Nurses seek better protective measures

Neither the prime minister nor the health ministerhas held a press conference since the lockdown began, but in daily briefings, Health Ministry officials have been optimistic, even insisting that the country is "over-prepared" when it comes, for example, to available PPE and hospital beds.

In his TV address this week, Modi struck a similar tone. "The path that India has taken within our limited resources has become a topic of discussion in the entire world today," he said.

But the specifics of a nationwide policy to tackle the virus remain elusive, Patel says.

When asked, for example, why the Health Ministry has not made public thelist of dedicated hospitals for treating COVID-19 cases, ministry official Lav Agarwal said, "We do not want people to unnecessarily feel panic and flood those hospitals."

He said anyone with symptoms should call official helplines.

Officials have also notdisclosed how many health workers have been infected even amid reportsof doctors and nurses contracting the virus and some dying from it, and at least one private hospital having to be sealed off because of an outbreak among staff.

On Wednesday, the United Nurses Association, one of the largest nurses' unions in the country, petitioned the Supreme Court, saying the government had notaddressed the risks faced by frontline workers.

The government told the court it would set up a helpline and respond to any grievance raised by a nurse within two hours.

"When the government says there is adequate PPE, they are perhaps limiting themselves to the COVID-19 dedicated hospitals, What about the rest?" Joldin Francis, the general secretary of the union's Delhi branch, told CBC.

"We have seen outbreaks in other hospitals. In the absence of mass testing, we do not know which patient might be carrying the virus, and we are working in conditions of great risk."

Keralaseems to be flattening its COVID-19 curve

One state that seems to have used testing effectively to contain the spread is Kerala.

The coastal state of 35 million on the southern tip of India has the best human development indices and public health infrastructure in the country. As soon as its first case of COVID-19 was detected on Jan. 30, the state government moved swiftly to test and contact trace, set up quarantine facilities and institute containment measures in areas reporting multiple cases.

The health measures have been backed by a welfare safety net, including financial support, food rations, community kitchens and special outreach for migrant labourers.

Kerala's approach seems to be working, with the number of active cases coming down, and the disease curve starting to flatten, the state's finance minister, Thomas Isaac, tweeted this week.

With two deaths out of 399 cases, it has the lowest case fatality rate in the country, at 0.5per cent.

Kerala's relative success stands out in a country where domestic public health spending is under two per cent of GDP - compared to about eight per cent in Canada and three per cent in neighbouring China.

Public health infrastructure, particularly across rural India, suffers from decades of neglect and absence of trained personnel. Hundreds of thousands of people die annually of preventable diseases, such as tuberculosis and malnutrition.

"Malnutrition is a significant co-morbidity for the coronavirus. If the virus spreads to the poor, or to populations such as Adivasi (indigenous communities) areas, we will have a public health disaster on our hands," said Ray.

He urged authorities to ramp up testing.

"The more you test, the more lives you will save, and the sooner you will bring the country out of the lockdown."