The numbers of officially confirmed cases are very low. But they’re likely masking a deeper problem in the world’s second-most-populous country.
At first glance, India seems like a coronavirus success story, with its relatively low number of cases compared with the rest of the world. But a closer look reveals a grim reality: It’s likely only months away from a major health crisis.
According to the government’s official numbers, as of March 24, the country has fewer than 500 total cases of Covid-19, and only nine people have died from the disease. For a country with a population of 1.3 billion people, the world’s second largest behind China, those figures seem almost too good to be true.
Unfortunately, experts say the numbers almost certainly are too good to be true, and may be masking a much larger outbreak.
Perhaps recognizing this possibility, Prime Minister Narendra Modi on Tuesday announced a three-week lockdown for all of India. “To save India and every Indian, there will be a total ban on venturing out of your homes,” he said in a national address.
Despite swift and early moves to restrict air travel, the central government’s main problem is the quality and scarcity of testing. Without the data from that testing, Indian health officials are being forced to make life-or-death decisions without reliable information about who does and who doesn’t carry Covid-19.
“We’ve been proactive, but blindfolded,” Shamika Ravi, a health policy expert at the Brookings Institution in India, told me.
That would be a challenge for any country, but for India it’s particularly devastating. Public health care in the country is poor. Private health care is expensive. About a quarter of the population is illiterate and thus may not be as aware of the danger. And a massive citizenry makes social distancing nearly impossible — a big issue when around 100 million people in the country are over the age of 60.
All of this has many extremely worried about what comes next. “If we follow the trajectory of Italy, for example, it would be a catastrophe, especially in the poorer states, which have next to zero capacity to cope with something like this,” said Manoj Joshi, an expert on Indian politics at the Observer Research Foundation in New Delhi.
To curb a growth in infections, the central government had been working with the nation’s 36 states and territories to impose curfews and lockdowns. But even then people didn’t take it too seriously, wandered outside, and didn’t follow general health and safety guidelines, experts say.
The lack of information and societal order has medical professionals fearing the worst.
“We expect 55 percent of the Indian people will get Covid-19 infection: 300 to 500 million cases over the next four months,” Dr. SP Kalantri, the medical superintendent of the Kasturba Hospital in central India, told me before Modi announced the lockdown. “If the current disease trajectory is anything to go by, we expect 1 million or 2 million deaths in India over a one-year period.”
“In Maharashtra, a state where I live, 60 million of 120 million are likely to get infected in a year,” he continued.
So although India may not be showing official signs of trouble now, the warning lights are clearly blinking red.
India acted fast but then dropped the ball on testing
No one I spoke with said India had failed to take the threat seriously. In fact, the government took pretty aggressive measures early on.
The first confirmed case in India was reported on January 30. A university student studying in Wuhan, China, had traveled back home to Kerala, a state on India’s southern tip, during vacation. Over the next four days, two more people in Kerala tested positive for the disease.
That launched the central government into action. Michael Kugelman, an India expert at the Wilson Center think tank in Washington, told me he noticed the country was already airlifting Indian nationals out of Wuhan during his trip to New Delhi in early February.
“Clearly the efforts to restrict travel from China were happening way back then, even though flights weren’t formally banned until a bit later,” Kugelman said. That would come on March 19, a final step after the country had already suspended tourist visas a week earlier.
But throughout that period, government officials were only testing people who had traveled internationally or had come into contact with someone who tested positive. Because of that focus, India had one of the lowest testing rates in the world as of March 13, as the chart below shows. (Note that the United States wasn’t much further ahead.)
What’s worse, those early efforts proved problematic on their own.
Jayaprakash Muliyil, one of India’s most renowned epidemiologists, told the Indian news site Scroll on Monday that those initial tests were “weak.” They didn’t specifically test for Covid-19, he said, but just any strain of coronavirus, including SARS and MERS.
“It would lead to many unnecessary positives and unnecessarily people being quarantined,” Muliyil continued. “But now we have excellent test kits with sensitivity and specificity almost next to 100 percent,” he said, adding that he expected India “will start testing, testing, testing” soon.
More testing is generally a good thing, but experts tell me there are two big problems with that optimism.
First, only the central government is currently authorized to conduct tests. That means the state leaders can’t take advantage of their networks to test their own people, assuming supplies were available.
Second, the policy for testing hasn’t changed: It’s still only for travelers or those who’ve been in contact with infected people. That leaves out hundreds of millions who may be carrying the disease but don’t know it.
Without a change to either stance, it’s likely India won’t get a firm grasp on the extent of the outbreak. “The testing protocol has to become more aggressive,” Brookings’s Ravi told me. “We are testing too few.”
But even if India had been testing perfectly from the start, it would still struggle to implement other critical measures needed to control the outbreak — namely, lockdowns.
Many Indians are openly disregarding local lockdown orders
Andy, who lives in the eastern state of West Bengal and requested Vox withhold his last name for security reasons, is worried about how his neighbors are dealing with the crisis.
During a recent trip to the grocery store in Kolkata, he found that many weren’t covering their mouths or using masks. Some, even, were spitting in public. “They should be more cautious and have more knowledge about what and what not to do,” he told me after answering a Vox call out for experiences around the world with coronavirus.
The lack of public adherence to health and safety requests led his state to impose a week-long lockdown on Monday. Other than getting food, medicine, or other necessary items, Andy and his parents must stay in their shared home. “It’s pretty fine — for now,” Andy said, chuckling.
Hundreds of millions of Indians are in similar circumstances.
Because India is so large, states have lots of power to govern themselves, though they coordinate their efforts with the central government. Government officials in states with larger outbreaks and more cosmopolitan populations have taken the most drastic measures.
For example, Maharashtra state, which has the nation’s financial hub of Mumbai as its capital, shut down nonessential businesses and trains until the end of March. Those undergoing quarantine in the state must be stamped on their left hand.
Sahiti Chedalavada, a 27-year-old IT specialist who lives in the city, says that even services for the well-off are struggling. “Bigbasket, the grocery delivery service I and many of my neighbors use, has been out of delivery slots for three days,” she told me. “Amazon has shifted to essentials-only delivery, but it’s still backed up.”
“Every delivery service is like this or worse,” Chedalavada said, while noting that she’s stocked up on products for weeks and has the luxury of working from home.
What’s universal, though, is that citizens everywhere continue to go outside in defiance of their local lockdowns.
Part of that may have to do with the country’s high illiteracy rate and poverty levels. “The population is illiterate and even its elite is uneducated, and therefore they have been taking it lightly until now,” says the Observer Research Foundation’s Joshi. “People only have a vague idea of what the virus is all about.”
The other part is that some people just don’t want to be cooped up inside — and it’s hard to enforce such a policy for millions of people, especially when some curfews and lockdowns were more robustly enforced than others.
That’s surely why Prime Minister Modi took the major step to impose a nationwide lockdown on all 1.3 billion Indians for three weeks.
“If we don’t handle these 21 days well, then our country, your family, will go backward by 21 years,” he said during Tuesday’s national address, adding that the government will provide support for medical equipment like masks and ventilators.
For experts, it’s a simply stunning decision.
“You can’t overestimate the significance and the profound challenges of shutting down a nation of more than a billion people,” the Wilson Center’s Kugelman said. “Modi surely understood the immense economic risks, especially in a country already experiencing one of its most serious slowdowns in years, of locking down for such a long period — and yet he opted to swallow that risk and go all in.”
“Modi is well known for making bold decisions,” he continued, “and this is his boldest by far.”
But it’s another bold decision Modi made half a year ago that has many people even more worried.
The coronavirus will hit hard in Kashmir
Last August, Modi’s government made a controversial move to usurp power from the nation’s only Muslim-majority state: the near-autonomous Jammu and Kashmir (J&K). Immediately, the central government put the area under brutal military lockdown to quash any dissent there.
Now, at a time when people especially need to trust their government in order to weather the coronavirus crisis, those in J&K clearly — and rightfully — don’t.
“It is a very tense and repressive environment that makes many Kashmiris mistrust the authorities and whatever actions they take,” the Wilson Center’s Kugelman told me. “The volatile dynamics in Kashmir introduce a unique level of complexity into Indian efforts to curb the spread of coronavirus there.”
J&K’s first case of coronavirus was reported last Thursday, and the nearby territory of Ladakh — which was once part of J&K until the government’s takeover last year — has 13 cases after a group traveled to Iran. That’s increasing fears that there will be a larger outbreak in the Kashmir area — which also shares a very long border with China.
A major part of the problem is that J&K’s 8 million people have no reliable access to the internet, which has alternated between being dramatically slowed down or shut off completely by Indian authorities. Even if locals wanted to get vital information about the disease from trusted sources, work from home, or continue their education online, they couldn’t.
“I can’t open even basic websites that provide information and advice about the pandemic,” Nayeem Rather, a freelance writer in Srinagar, J&K’s largest city, told BuzzFeed News last week.
Mir Moien, a medical student from J&K, also shared his frustrations with BuzzFeed. After conducting a Google search for coronavirus information, he realized any links he clicked on wouldn’t download. Even information coming over WhatsApp, the texting platform widely used by Indians, doesn’t load. “It’s a catastrophe,” Moien said.
Communications remain so slow and restricted that it’s especially troubling for physicians who treat patients. The health care system in the region is already poor, but the restrictions on the internet are making it even harder to provide adequate care.
Iqbal Saleem, a surgery professor at Government Medical College in Srinagar, tweeted last week about his troubles simply downloading a manual for doctors on how to treat Covid-19.
This is so frustrating.. Trying to download the guidelines for intensive care management as proposed by docs in England.. 24 Mbs and one hour.. Still not able to do so… @MirzaWaheed @naseerganai @islahmufti @Samaanlateef @DrKaloo
— Iqbal Saleem (@DrIqbalSaleemM1) March 19, 2020
Kugelman noted another deeply concerning possibility: “There’s also reason to fear, given how Kashmir is marginalized, that officials in New Delhi won’t act as expeditiously to ramp up underserved medical facilities and supplies there as it will to bring similar reinforcements to other areas of the country,” Kugelman said. “Old habits die hard.”
Between the lockdown and current tensions, few have any real hope. “If it [coronavirus pandemic] happens here, we will be devastated,” an unnamed veteran doctor from the area told Al Jazeera on Monday. “We will die like cattle.”
India isn’t ready for a major health crisis
As mentioned above, states control their own public health care systems in India — and Brookings’s Ravi told me that the biggest states tend to have the worst ones. That could pose major problems for millions of patients who may need to seek care should they be infected with the coronavirus.
Ravi also noted that 75 percent of health care in India is provided at private hospitals, which experts say generally are better-run and better-equipped. While that may be good news for those who can afford such treatment, that kind of support will be out of reach for the millions of poor in the country. Private hospitals are already turning away some prospective patients who believe they might have the disease.
As the Caravan magazine reports, in India, “government hospitals are ill-equipped, and the private hospitals are not accountable to anyone.”
This is why Indian officials are sounding the alarm. “If we reach stage 3 of the pandemic” — meaning community transmission — “India’s healthcare system will collapse,” an unnamed Ministry of Health official told the Sunday Guardian last week.
The problem, though, is that India is probably already there. “Community transmission has started,” Muliyil, the epidemiologist, told Scroll on Monday. “We know this from the fact there have emerged a few cases without any contact or travel history.”
This is what has Kalantri, the doctor in central India, extremely worried. His nearly 1,000-bed teaching hospital is already making tons of adjustments to get ready for an influx of patients.
“We created an isolation ward and an [intensive care unit] for patients suspected to have or confirmed with a Covid-19 infection,” he told me. He continued:
We stopped teaching medical students and closed all our research activities. We asked colleagues from the departments of anatomy, physiology, biochemistry, pathology, pharmacology, and microbiology to lend us a helping hand in the current crisis. We stopped all surgeries, postponed our peripheral rural health care activities, limited the number of ward admissions, and changed the roles of health professionals in the hospital.
“The outbreak would surely test our capacity,” he added.
Modi’s lockdown may put a brief pause on the coronavirus crisis in his country, then, but the situation is likely to get worse before it gets better.