scenarios, airport-screening is likely to have missed over half of all infected passengers.

In fact, most
cases in the US were not detectable when they passed through airport-screening, and more cases were
detected several days later, when many who had passed through screening needed medical assistance.

But inexplicably, in India, only a few of those not detected in airport-screenings have sought medical
help. Therefore, India has a strange situation. Where are these people?

Disease spread: absent or hidden?

The disruption of normal life and closure of many healthcare facilities have made it difficult for people to
receive medical attention. A Brookings Institute study of India’s healthcare system in 2004-2014 found
that at the end of that decade, fully 75% of outpatient care and 55% of inpatient care was fulfilled by the
private sector. Similarly, the disruption caused by the lockdown has contracted healthcare facilities
available, especially in the private sector, and disrupted access to doctors and hospitals.

There have been news reports from different parts of India about people walking or cycling with
patients to reach far-flung public health facilities. While a few elective surgeries and treatments can be
postponed, in India many are in line awaiting their turn to receive urgent treatment and surgeries. In
addition, there is an evident tendency among many to avoid the healthcare system for fear of being
tested for COVID-19. People seem more afraid of the social consequences of testing positive and the
quarantine than of the virus itself. These attitudes in turn contribute to rendering the disease, and
information about it, invisible.

There is an assumption that if there are as many deaths in India as there are in, say, China, Europe, the
US or the UK, then it would be easily noticed. But this isn’t necessarily so! First, the lockdown has most
likely increased the mortality above the normal, or at least the number of deaths per day even without
COVID-19. Second, according to a report on the Medical Certification of the Cause of Death in 2017
(published by the Registrar General of India in 2019), the cause is medically certified for only 22% of
registered deaths.

The annual mortality rate for India is nearly 7.3 per thousand. The corresponding deaths per district
works out to be about 37 per day. A thousand additional deaths in a day at the country-level in a day
translates to less than two additional deaths per district. This is likely to go unnoticed. Only when there
are many deaths in a cluster will the uptick become noticeable. Therefore, until normal life is restored
and all fears are dispelled, the virus’s presence in India is likely to be hidden for the most part even as it
spreads.

It’s possible there are other, more problematic reasons that explain the peculiarities of India’s data.
However, there’s no information or data available in the public domain to indicate India is making its
best efforts to assess the disease’s spread. As Priyanka Pulla wrote in  The Wire Science on March 20, the
central agencies responsible for the technical aspects of the country’s COVID-19 response – Indian
Council of Medical Research (ICMR) and the National Centre for Disease Control – have been very
opaque, staying tight-lipped about their surveillance mechanism.

Estimating realistic numbers

Officials of the Union health ministry have consistently adopted a conservative and tepid approach to
monitoring and COVID-19 disease surveillance. The number of India’s tests per million people is 149,
compared to the US’s 8,894, Canada’s 11,591 and Germany’s nearly 15,730. There was considerable
delay in expanding the scope of testing as well. And when the ICMR did expand it, it did so reluctantly,
without a smart plan to rapidly assess the virus’s spread in different parts of India. Additionally, there
seems to be no emphasis on developing a ‘heat map’ of the disease’s presence across the country to
quickly identify emerging hotspots in coordination with state authorities.

The health ministry updated the scope of testing through notifications