The COVID-19 surge in India over the summer has been staggering. It took five and a half months from the beginning of the pandemic for India to reach one million infections. The second million took three weeks. The third million and the fourth million each took two weeks. India now has registered around 4.3 million confirmed cases. But serological surveys suggest that the true total is several times higher, meaning that India has probably overtaken the United States in having the highest number of coronavirus cases in the world. In August, reports emerged of infections among remote tribal communities in the Andaman and Nicobar Islands in the Bay of Bengal, a testament to how deeply the virus has penetrated the country.
The Indian government, much like its American and Brazilian counterparts, did not base its decisions on the soundest scientific understandings of the coronavirus. Instead, it handled the pandemic in a manner that forces the country to make an unenviable choice between rescuing its economy or slowing the spread of the disease. Now, the epidemic is rampant and likely to remain so into early 2021.
EARLY MISTAKES
Inevitably, given India's size, the country's struggle with the coronavirus has been continental in scale. India has twice the population but a third of the land area of Europe. The 28 Indian states, each with its own language, are almost akin to European countries. State governments took the lead in responding to the virus, with vastly divergent results. India's first documented COVID-19 cases came at the end of January, when Indian medical students studying in Wuhan, China, returned to the southern state of Kerala. Drawing on its experience quashing an outbreak of the Nipah virus in 2018, the government of Kerala decided to test and quarantine all returnees even in the absence of any overarching national guidelines or direction from the World Health Organization. Three students tested positive for COVID-19, but no secondary infection ensued, thanks to stringent quarantine measures. By contrast, the western state of Maharashtra-home to the metropolis of Mumbai-failed to impose sufficient screening and quarantine measures on travelers arriving from the Middle East and the West. To date, Kerala, with a population of 35 million, has reported only 359 COVID-19 deaths; Maharashtra, with a population of 114 million, has reported more than 27,000.
The central government took little action at the national level in February, as the virus flared in other countries. Infections began to slowly spread in Indian metropolitan areas in March. Even as the case numbers climbed, however, officials didn't seem to perceive the magnitude of the impending threat. They comforted themselves with the relatively low number of reported cases in Indiacompared to other countries. On March 1, Italy (with a population of 60.4 million) had 1,702 confirmed infections, while India (with a population of around 1.4 billion) had only the three in Kerala. On March 20, the number of confirmed infections in Italy had jumped to 59,158, but India'stotal was still fairly low at 249. Many Indian government officials misinterpreted these figures as evidence that some unknown factor protected Indians from the virus-the high rates of vaccination against tuberculosis in India, for instance, or the benefits of vegetarianism, or even (as some political leaders suggested) the supernatural protection of religious beliefs.
They had misread the situation in the first place by overemphasizing the reliability of confirmed statistics. A country of India's size and with its uneven distribution of resources always risks undertesting and undercounting. But more important, epidemiologists in the West were already coming to the conclusion that Italy's spike in cases in the spring had been months in the making and that the disease must have arrived late in 2019. Indian officials should have realized that what was happening in Italy could happen in India; Italy just had a head start.
The Indian government might have been less complacent if it had more infectious disease epidemiologists in its ranks. Unlike many other countries, India does not have a formal public health wing in its central government. When India won independence in 1947, it folded the public health bureaucracy into the Ministry of Health, in effect eliminating the department. The Ministry has directorates focused on health-care services and research but no division focused on public health, which, under usual circumstances, would be responsible for disease surveillance and the detection, control, and elimination of infectious disease outbreaks. India does not have any meaningful nationwide capacity for real-time public health surveillance.
That lack of relevant expertise in government decision-making led to major mistakes. As COVID-19 numbers ticked upward, the government ordered a 14-hour curfew on March 22, subscribing to the notion that the virus was transmitted on surfaces and would die in 12 hours. Two days later, as case numbers continued to climb, government officials seem to have panicked and ordered a three-week lockdown of the entire country to interrupt transmission. The lockdown came at midnight with a mere four hours of warning, throwing millions of lives into disarray. In towns throughout the country, people crowded around shops and markets to stock up for three weeks, producing exactly the opposite of the desired outcome and allowing the further spread of the disease.
If the three-week lockdown was meant to preempt the escalation of the pandemic, it surely failed. By the end of that period, case numbers had shot up 2,100 percent. Authorities doubled down-tripled down, in truth-on the lockdown, extending it three times, without ever flattening the curve.
The lack of epidemiological expertise in government decision-making was glaring. It was not necessary to insist on a nationwide preemptive lockdown, which extended even to states and areas without a single documented infection. Instead, the government should have urged the universal wearing of masks, which would have allowed many economic activities to continue. It should have encouraged the selective quarantining of people particularly at risk to the disease-the elderly and those with serious underlying health conditions-which would have prevented many deaths. But above all, Indian leaders themselves did not understand the epidemiological crisis in front of them; their lack of understanding filtered down to the public, making it more difficult to alter behavior. With greater expertise guiding policy, officials could have administered a "social vaccine," both slowing the spread of the disease and protecting the economy. Instead, their actions did not meaningfully control the virus and threw the economy off a cliff.
SILVER LININGS
The total number of cases in India in early September is officially around 4.3 million, but the actual number may be between 20 and 40 million. From an epidemiological perspective, now is the worst time to lift the lockdown, as infection counts will continue to rise. But the lockdowns have taken a devastating toll on the Indian economy. India's GDP has contracted by nearly a quarter-23.9 percent-leading to real hardship and deprivation for millions of people. The government has now prioritized the economy over stymying the disease and rightly so, as the lockdowns seem to have achieved little.
There are a few silver linings to this dark cloud. The death rates in India seem to be much lower than those in other parts of the world, especially in the West. For instance, Italy's case fatality rate is 14 percent, while India's is just two percent. Of course, Indian figures are not always reliable, but even if the true Indian rate is a bit higher-three or four percent-it is still substantially lower than Italy's rate. That gulf is a measure not of the quality of Indian health care but rather of the relatively young age of the Indian population. India's median age is 28 years; Italy's is 47. Six percent of Indians-and 23 percent of Italians-are over the age of 65. Older people are more vulnerable to complications resulting from COVID-19.
The virus may also be growing weaker in virulence but more infectious over time. The relatively late spread of COVID-19 in India (compared to its early spread in Italy, for example) gives Indians a better chance of benefiting from the possible weakening of the disease. Such a change might help explain the relatively low rate of death in India despite the lack of strong antiviral remedies for COVID-19. Drugs in current use to treat the disease, such as hydroxychloroquine, remdesivir, corticosteroids, and convalescent plasma can sometimes reduce the disease's deadliness, but in Indiathese therapies are available only to the very rich.
India will have to learn to live with rising coronavirus numbers for a little while-in the best case scenario, just a few more weeks-but eventually, the daily numbers will slowly decline, and the pressure on the country's health-care infrastructure will ease. This is the natural progression of infectious diseases. In other countries, more people contracted COVID-19 after the peak of infections than before the peak. That is because, by my rough estimate, a national COVID-19 outbreak tends to reach its peak when about a quarter of the population has achieved herd immunity; infection rates will dip after the peak, daily new case counts will drop, but three-quarters of the population will still remain susceptible. In India, that means that the number of coronavirus cases in the country-potentially 40 million right now-will have to double three times to 320 million before the country passes its peak and the numbers begin to subside. With lockdown restrictions eased, that spread could occur in as little as 30 days, but it could take longer still. Indians should expect the epidemic phase of the virus to extend into early 2021 before the number of new cases becomes low and steady and the country reaches the endemic phase of infection.
This article was originally published on ForeignAffairs.com.
