A grave health crisis is unfolding in India as the Covid-19 situation worsens rapidly in the country’s densely populated cities as well as in its poor hinterlands inhabited by nearly 900 million people. India has jumped to the second most heavily affected nation after the United States, reporting over four million confirmed cases. The country has been recording the most daily cases as well as the worst case trajectory since August.
It took more than five months for India to reach the bleak milestone of one million coronavirus cases in July. The next million came in just 21 days when its Covid-19 tally crossed the two million mark on 7 August. The third million was faster and the country crossed it in just 16 days on 23 August. It went past four million, within 13 days, on 5 September.
The worst, it seems, has yet to come as the peak stage of coronavirus cases in India is expected to peak in mid-November, and the country is predicted to surpass the US by the end of September to emerge as the world’s new coronavirus epicentre.
On 7 September, data from India’s Ministry of Health revealed that the total number of cases amounted to 4.2 million, while the death toll recorded was 71 642. Though the fatality rate declined to 1.7%, there were about 882 542 active cases of the infection in the country, comprising 20.99 % of the total caseload. More than half of Covid-19 cases reported in India are in the 18-44 years age group, the data further stated.
The states of Maharashtra, Andhra Pradesh, Tamil Nadu, Karnataka and Uttar Pradesh remain severely affected, with metropolitan cities like Pune, Mumbai, New Delhi and Chennai being the worst hit. But the new hotspots continue to feed surges as the virus has spread to rural villages where case counts are now surging, weighing heavily on an already overwhelmed healthcare system. Even states like Kerala, which was once widely lauded for flattening the curve, are now witnessing a surge in cases, with state chief minister Pinarayi Vijayan saying the situation was “not good”.
Second wave expected
According to Randeep Guleria, director of the All India Institute of Medical Sciences, the country’s premier medical institute, the daily cases will continue to rise for some more months as India is witnessing a second wave in some regions. “We can’t say that the pandemic will not spill over to 2021, but what we can say is that the curve will be flatter instead of rising very steeply. We should be able to say the pandemic is ending early next year,” Guleria noted.
Ramanan Laxminarayan, director of the Centre for Disease Dynamics Economics and Policy, which is based in New Delhi and Washington DC, said the disease was moving from urban to rural areas as well as moving from states with better healthcare infrastructure to other places with poorer healthcare systems. “That all means that there will be more deaths, but they will not be counted because they will not be visible anywhere.”
Experts assert that the epidemic in India is now at a stage where government interventions are unlikely to make any substantial difference to the speed with which new cases are being detected, and that more testing may be one of the reasons for the spike in cases. The Indian government has also argued the latter. The health ministry has reported more than one million tests conducted a day, but health experts fear that owing to a reliance on antigens or viral protein screening, these test results may be inaccurate. It has also highlighted the low mortality rate as an indicator of its timely and effective clinical management of the patients in critical care.
But the noted British medical journal The Lancet has raised questions about India’s Covid-19 mortality data, saying it is unclear how suspected or probable attributable deaths are being included in mortality estimates. Giridhara R Babu, an epidemiologist at the Public Health Foundation of India, told The Lancet that in rural areas, where most of India’s population lives, most deaths occur outside the hospital, which can delay their registration. “Among the deaths registered under the civil registration system, only 22% are medically certified nationally with cause of death.”
The cruel lockdown
India enforced a strict lockdown on 25 March to allow healthcare workers to plan how to manage the crowded nation’s impending coronavirus surge. When the government first imposed the lockdown, which lasted two months, it had barely recorded 500 cases and 10 deaths. It was then extended and gradually relaxed in seven subsequent phases. When it was over, the outbreak was considered relatively under control.
India’s initial strategy to contain the pandemic was focused on the scrutiny of incoming travellers at international airports and closing down state borders and transportation services. Prime Minister Narendra Modi gave his countrymen only four hours’ notice before declaring the nationwide shutdown, putting the lives of millions of poor migrant workers at severe risk.
The lockdown came with hardly any consultation with the state governments or any announcement about alternative food and shelter arrangements for the suddenly unemployed. Dozens died without food and in road accidents as they trekked hundreds of kilometres to get home. About 20 million Indian migrant workers from overcrowded and undeveloped urban areas with high infection rates travelled back home, which is how the disease spread all over the country.
The damage to the economy was also devastating for many and ultimately led to the worst slump in economic growth in decades. With the economic downturn, the Modi government was forced to open up even with the virus still running rampant. The government continues to take steps to return to normal, including the reopening of underground trains and plans for limited sporting and religious events. Critics have argued that the harsh lockdown came in reverse order, which not only led to a recession but was especially harsh on the impoverished populace and informal sector workers.
Economic precariousness means that the shutdowns necessary to contain the pathogen are now intolerable for the millions of poorest and most marginalised people. The pandemic especially exacerbates the problems for those living in densely packed urban clusters, which offer ideal conditions for the virus to spread. The residents of these areas are often left out of emergency measures, such as free medical testing, and generally lack access to healthcare services, hygienic toilets and clean water.
Poor healthcare infrastructure
India’s government health spending, at a little over 1% of gross domestic product, is among the lowest in the world. A lack of hospitals, missing doctors, ill-equipped health professionals and shortage of funds have dogged the Indian health sector for decades.
According to India’s 2019 national health profile data, the availability of government beds is abysmally low, with just 0.55 beds available per 1 000 people on average. This falls further to 0.11 beds per 1 000 in 12 major states. Public hospitals were already severely understaffed, with a nationwide shortage of 600 000 doctors and two million nurses. About 90% of India’s poorest do not have any form of private or government health insurance. A national sample survey in 2016 revealed that at least a quarter of allopathic physicians did not have the requisite qualifications. India has only about 1631 Covid-19 testing centres for 1.3 billion people.
The exponential surge in Covid-19 cases has quickly overwhelmed underfunded hospitals, especially in poorer and densely populated states such as Uttar Pradesh and Bihar. Limited and overstretched medical resources make any response to the crisis more challenging. British newspaper the Daily Telegraph reported that more than 80% of newly qualified doctors in the state Kerala quit after their wages were slashed, despite the desperate need for medics.
Additionally, a surge of misinformation over claimed cures that has swept the country has added to the worries of health experts and scientists. Some Indian legislators have claimed cow urine and cow dung could cure those infected with the coronavirus – assertions with no scientific basis. India’s government has suggested that a cocktail of six herbs could help treat the virus.
This disinformation has come from no less than Modi himself, who proclaimed that the country would defeat the pandemic within 21 days, taking a war reference from the Hindu mythological epic Mahabharata. “Today, the entire country is fighting a war against coronavirus… Mahabharata was won in 18 days but the war against coronavirus will take 21 days,” Modi said.
Writing in The Atlantic, journalist Vidya Krishnan highlights that in the years since Modi and his Hindu nationalist Bharatiya Janata Party (BJP) came to power in 2014, Indian authorities have tolerated unscientific thinking and made a virtue of anti-intellectualism.
“Ministers in Modi’s government have repeatedly proclaimed the superiority of Indian systems over modern medicine; the department overseeing traditional treatments has been upgraded to a full ministry; and godmen running multibillion-dollar empires sell unproven Ayurvedic products,” she writes. “And they have more actively linked traditional medicine with religiosity, aiming to reclaim yoga’s Hindu provenance and using traditional systems as a vehicle for promotion of a Hindu nationalist ideology.”
Putting politics before the pandemic
Critics argue that Modi’s government compromised India’s Covid-19 preparedness by holding legislative assembly elections in Delhi in February, committing anti-Muslim atrocities in the aftermath of a profoundly provocative Citizenship Amendment Act passed last year, and tightening the government’s grip over the disputed Muslim region of Kashmir. Added to these were US President Donald Trump’s visit to India in late February, and the politics of regime change in the state of Madhya Pradesh and Rajasthan preoccupying much of the regime’s attention.
Writing in the digital news publication Scroll.in, Indian economist Pranab Bardhan argues that the Indian government was not only unprepared, but also wasted crucial time initially by indulging in politics rather than taking precautions against the pandemic.
“Much of February, particularly around the time of the Delhi state elections, went in majoritarian hate-mongering against the minority Muslim community and all dissenters against a highly discriminatory Citizenship Act. The protesting women of Shaheen Bagh were the enemy, more than the pandemic,” he notes.
Bardhan adds that the regime welcomed Trump at a stadium packed with 110 000 people at a time when restrictions were already in place in some countries. “The first half of March, the central leadership was preoccupied with toppling an opposition state government.”
Echoing similar views, economists Debraj Ray and S Subramanian also underscored that the response of the Modi government exhibited “a perverse politics of visibility: draconian on high-profile measures such as lockdown, weak on the measures that are less easily observed”. The duo notes that the government’s inadequate and impetuous management of the pandemic “reflects an effort to win international approval by following the paradigm of advanced economies, without heeding the ethical urgency of providing a robust program of relief, both medical and economic”.