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India continues to remain ranked 43rd on an annual World Competitiveness Index compiled by Institute for Management Development (IMD) with some traditional weaknesses like poor infrastructure and insufficient education investment keeping its ranking low, the international business school said on Tuesday.

Singapore has retained its top position on the 63-nation list.

Denmark has moved up to the second position (from 8th last year), Switzerland has gained one place to rank 3rd, the Netherlands has retained its 4th place and Hong Kong has slipped to the fifth place (from 2nd in 2019).

The US has moved down to 10th place (from 3rd last year), while China has also slipped from 14th to 20th place. Among the BRICS nations, India is ranked second after China, followed by Russia (50th), Brazil (56th) and South Africa (59th).

India was ranked 41st on the IMD World Competitiveness Ranking, being produced by the business school based in Switzerland and Singapore every year since 1989, but had slipped to 45th in 2017 before improving to 44th in 2018 and then to 43rd in 2019.

While its overall position has remained unchanged in the 2020 list, it has recorded improvements in areas like long-term employment growth, current account balance, high-tech exports, foreign currency reserves, public expenditure on education, political stability and overall productivity, the IMD said.

However, it has moved down in areas like exchange rate stability, real GDP growth, competition legislation and taxes.

Arturo Bris, Head of Competitiveness Center at IMD Business School, said India continues to struggle on the list and the recent country rating downgrade by Moody’s reflects the uncertainties regarding the economy’s future.

"In our ranking this year, we again emphasize the traditional weaknesses of India -- poor infrastructure, an important deficit in education investment, and a health system that does not reach everybody. For India to follow the path of China, it must stress its intangible infrastructure," Bris said.

"In a less global world, with China, USA, and Europe looking inwards, currencies like the rupee (and the Brazilian real for instance) are going to suffer and display high volatilities.

"Moody’s has threatened the country with a downgrade to junk and that would put India in a terrible position to attract foreign capital. So the urgency for the government should be to fix the short-term problems—and this requires to improve the credibility of the government itself," Bris added.

With the exception of Singapore, the Philippines, Taiwan and the Korean Republic, most Asian economies dropped in rankings this year, the IMD said.

The reason for the Asian economies’ less stellar performance as a region, this year is partly the result of the trade frictions between China and the US, particularly because these economies are highly dependent on trade with China.

About Singapore, which moved to the top rank last year, the IMD said its position is largely driven by the relative ease of setting up business, availability of skilled labour and its cutting-edge technological infrastructure.

The IMD said the impact of COVID-19 on the competitiveness ranking has partially been captured by executives’ opinions about the effectiveness of the different health systems.

In the ASEAN countries included in the survey, only Singapore and Thailand have a positive performance in the effectiveness of the health infrastructure.

Washington, Apr 28: After nearly three weeks in an intensive care unit in Los Angeles, doctors treating 41-year-old Broadway actor Nick Cordero for COVID-19 were forced to amputate his right leg.

The flow of blood had been impeded by a blood clot: yet another dangerous complication of the disease that has been bubbling up in frontline reports from China, Europe and the United States.

To be sure, so-called "thrombotic events" occur for a variety of reasons among intensive care patients, but the rates among COVID-19 patients are far higher than would be otherwise expected.

"I have had 40-year-olds in my ICU who have clots in their fingers that look like they'll lose the finger, but there's no other reason to lose the finger than the virus," Shari Brosnahan, a critical care doctor at NYU Langone said.

One of these patients is suffering from a lack of blood flow to both feet and both hands, and she predicts an amputation may be necessary, or the blood vessels may get so damaged that an extremity could drop off by itself.

Blood clots aren't just dangerous for our limbs, but can make their way to the lungs, heart or brain, where they may cause lethal pulmonary embolisms, heart attacks, and strokes.

A recent paper from the Netherlands in the journal Thrombosis Research found that 31 percent of 184 patients suffered thrombotic complications, a figure that the researchers called "remarkably high" -- even if extreme consequences like amputation are rare.

Behnood Bikdeli, a doctor at New York-Presbyterian Hospital, assembled an international consortium of experts to study the issue. Their findings were published in the Journal of The American College of Cardiology.

The experts found the risks were so great that COVID-19 patients "may need to receive blood thinners, preventively, prophylactically," even before imaging tests are ordered, said Bikdeli.

What exactly is causing it? The reasons aren't fully understood, but he offered several possible explanations.

People with severe forms of COVID-19 often have underlying medical conditions like heart or lung disease -- which are themselves linked to higher rates of clotting.

Next, being in intensive care makes a person likelier to develop a clot because they are staying still for so long. That's why for example people are encouraged to stretch and move around on long haul flights.

It's also now clear the COVID-19 illness is associated with an abnormal immune reaction called "cytokine storm" -- and some research has indicated this too is linked to higher rates of clotting.

There could also be something about the virus itself that is causing coagulation, which has some precedent in other viral illnesses.

A paper in the journal The Lancet last week showed that the virus can infect the inner cell layer of organs and of blood vessels, called the endothelium. This, in theory, could interfere with the clotting process.

According to Brosnahan, while thinners like Heparin are effective in some patients, they don't work for all patients because the clots are at times too small.

"There are too many microclots," she said. "We're not sure exactly where they are."

Autopsies have in fact shown some people's lungs filled with hundreds of microclots.

The arrival of a new mystery however helps solve a slightly older one.

Cecilia Mirant-Borde, an intensive care doctor at a military veterans hospital in Manhattan, told AFP that lungs filled with microclots helped explain why ventilators work poorly for patients with low blood oxygen.

Earlier in the pandemic doctors were treating these patients according to protocols developed for acute respiratory distress syndrome, sometimes known as "wet lung."

But in some cases, "it's not because the lungs are occupied with water" -- rather, it's that the microclotting is blocking circulation and blood is leaving the lungs with less oxygen than it should.

It has just been a little under five months since the virus emerged in Wuhan, China, and researchers are learning more about its impact every day.

"While we react surprised, we shouldn't be as surprised as we were. Viruses tend to do weird things," said Brosnahan.

While the dizzying array of complications may seem daunting, "it's possible there'll be one or a couple of unifying mechanisms that describe how this damage happens," she said.

"It's possible it's all the same thing, and that there'll be the same solution."