India continues to face the world’s most devastating wave of the coronavirus pandemic, an onslaught of infections and deaths that has overwhelmed the nation’s health-care system and prompted lockdowns across the country. Each day now brings a world record in new cases per day, with the nation reporting more than 400,000 on Saturday, and more than 390,000 on Sunday — the 11th straight day more than 300,000 cases have been confirmed. Though international aid continues to arrive, including from the U.S., well over 3,000 people continue to die every day. 3,700 new deaths were reported on Sunday. Both the number of deaths and infections are via the government’s official count — which is definitely much lower than the actual numbers of sick and dying, according to experts. Below is an ongoing look at the unprecedented crisis, including new developments and the likely consequences.
When will the wave end?
A team of scientists which advises India’s government said Friday that according to their model, the wave of COVID cases may peak sometime in the coming days. A group of researchers at CLSA in Hong Kong, however, have predicted that the current wave won’t peak until June, while the State Bank of India suggested it would be around the third week of May in a report which came out a week ago.
India’s vaccine shortage will last months, says the embattled CEO of its biggest vaccine manufacturer
Serum Institute CEO Adar Poonawalla told the Financial Times on Sunday that the country’s severe vaccine shortage will persist through July, and deflected blame over the shortage to India’s government. Poonawalla, who left India for the U.K. with his family two weeks ago, previously said he had left the country in part due to threats he received from government officials, but downplayed the safety concerns to the FT.
A spotlight on the longstanding inequality in India’s health system
Writing for STAT News, longtime Times of India health journalist Kalpana Jain explains that while the current breakdown of India’s health system is the most tragic she has ever seen — the neglect that helped cause it has been an ongoing tragedy for decades:
India’s health care system was envisaged soon after its independence in 1947 as a three-tier system that could cover the entire country. It was to have a primary care system at the village level, a secondary care system to cover smaller urban centers, and tertiary care for specialized treatment. Over the years, though, the emphasis moved to for-profit tertiary care hospitals, mainly in big cities, with state-of-the-art that provided care mainly to the urban rich. Profits from these hospitals, which go into paying the high salaries of doctors and top executives, took precedence over attempts to regulate them or stop malpractice, such as overcharging patients or unnecessary surgeries.
Successive governments before Modi’s supported this unplanned growth, paying little heed to the health infrastructure that was underfunded, poorly staffed, and falling apart. Sushma Swaraj, a senior politician in the Bharatiya Janata party — today’s ruling party — who I interviewed in 1999 on the party’s absence of focus on health care in its parliamentary election manifesto, told me, “Health is a thing for the rich. We in India have to focus on getting bread to the poor.” …
The fact is that the poor in India have struggled to get health care for decades. Most health expenditures in India are paid for out of pocket and paying for health care is among the leading things that push people below the poverty line. A 2017 study by the Public Health Foundation of India found that health expenses were responsible for driving 55 million Indians into poverty between 2011 and 2012. As many as 90% of the poor have no health insurance.
The Hindu’s former health editor, Vidya Krishnan, described India’s health system inequality as a symptom of “moral malnutrition” in an Atlantic piece last week:
Our doctors are among the best trained on the planet, and as is well known by now, our country is a pharmacy for the world, thanks to an industry built around making cost-effective medicines and vaccines. What is evident, however, is that we suffer from moral malnutrition—none of us more so than the rich, the upper class, the upper caste of India. And nowhere is this more evident than in the health-care sector.
India’s economic liberalization in the ’90s brought with it a rapid expansion of the private health-care industry, a shift that ultimately created a system of medical apartheid: World-class private hospitals catered to wealthy Indians and medical tourists from abroad; state-run facilities were for the poor. Those with money were able to purchase the best available care (or, in the case of the absolute richest, flee to safety in private jets), while elsewhere the country’s health-care infrastructure was held together with duct tape. The Indians who bought their way to a healthier life did not, or chose not to, see the widening gulf. Today, they are clutching their pearls as their loved ones fail to get ambulances, doctors, medicine, and oxygen. …
[T]here is no shortcut to public health, no opting out from it. Now the rich sit alongside the poor, facing a reckoning that had only ever plagued the vulnerable in India.
Members of India’s COVID task force are calling for another national lockdown
According to the Indian Express, some of the country’s top pandemic officials have been “pushing hard” for another lockdown over the last few weeks. Those who spoke with the Express cited the rampant community spread across the country, growing anger within the overwhelmed medical community, and the unfolding disaster in rural areas as reasons the lockdown was needed.
India’s Supreme Court called for more lockdowns on Sunday, as well, as did the president of the Confederation of Indian Industry.
In an interview with the Indian Express on Friday, top U.S. infectious disease expert Dr. Anthony Fauci also said that India should strongly consider instituting a temporary national lockdown:
There is the immediate, the intermediate, and the long range. I think the most important thing in the immediate is to get oxygen, get supplies, get medication, get PPE, those kinds of things but also, one of the immediate things to do is to essentially call a shutdown of the country. … Literally, lock down so that you wind up having less spread. No one likes to lock down the country. Well, that’s a problem when you do it for six months. But if you do it just for a few weeks, you could have a significant impact on the dynamics of the outbreak.
It’s not clear that Prime Minister Narendra Modi is even considering another national lockdown, however, particularly after the poorly planned first one, starting in March of last year, caused so much chaos. In the meantime, the central government has left lockdown decisions up to state and municipal governments, and at least 11 states and union territories have instituted lockdowns across much of the country amid the current wave.
India’s lockdown during the pandemic’s first wave led to a humanitarian disaster
Prime Minister Narendra Modi ordered a nationwide lockdown on March 24, 2020 as the first wave of the pandemic swept the globe. Though there were only several hundred confirmed cases of COVID-19 in India at the time, he shut down public transportation and told the nation of nearly 1.4 billion people that they needed to remain in their homes for the next three weeks — and only gave them four hours notice before one of the world’s strictest lockdowns began.
Tens of millions of migrant workers were left stranded in urban areas, suddenly without work, income, or food. Many workers tried to walk or bike hundreds of miles home to their villages, and at least hundreds died in the attempt, either from accidents or exhaustion. (The full death toll remains unknown.)
As the humanitarian crisis worsened, the government set up more than 4,600 emergency trains to transport workers back to their villages — but most passengers were not screened for the coronavirus before they boarded and other precautions like social distancing went unfollowed and unenforced. As a result, COVID spread on the trains — and wherever passengers got off. It led to some of the the nation’s worst initial outbreaks of infection and death, often in rural communities where health systems were already inadequate. As the New York Times explained late last year, “the special trains operated by the government to ease suffering — and to counteract a disastrous lack of lockdown planning — instead played a significant role in spreading the coronavirus into almost every corner of the country.”
By all appearances, India’s central government, including its COVID task force, simply didn’t consider what the lockdown would mean for the country’s massive migrant workforce. And then they mismanaged the consequences so poorly that the lockdown both stopped and facilitated the spread of COVID-19 across India.
India’s vaccine czar left the country with his family, citing threats against him
Adar Poonawalla, the CEO of Serum of Institute of India, the largest vaccine manufacturer in the world, including the AstraZeneca COVID vaccine in India, moved to the U.K. with his family just before the country restricted travel from India a week ago. In an interview with the Times of London, Poonawalla said the decision was in part due to the harassment he was receiving:
The calls come from some of the most powerful men in India. They come from the chief ministers of Indian states, heads of business conglomerates and others demanding instant supplies of Covishield, as the AstraZeneca vaccine is known in India. “ ‘Threats’ is an understatement,” Poonawalla says. “The level of expectation and aggression is really unprecedented. It’s overwhelming. Everyone feels they should get the vaccine. They can’t understand why anyone else should get it before them.”
The calls begin cordially, but when Poonawalla explains that he cannot possibly meet the callers’ demands “the conversations go in a very different direction”, he says. “They are saying if you don’t give us the vaccine it’s not going to be good … It’s not foul language. It’s the tone. It’s the implication of what they might do if I don’t comply. It’s taking control. It’s coming over and basically surrounding the place and not letting us do anything unless we give in to their demands.”
“Everything falls on my shoulders but I can’t do it alone,” he continued. “I don’t want to be in a situation where you are just trying to do your job, and just because you can’t supply the needs of X, Y or Z you really don’t want to guess what they are going to do.”
What caused the wave?
The World Health Organization recently citied a “perfect storm” combination of three factors for the horrifying surge of new COVID cases in India: low vaccination rates, mass gatherings, and more contagious COVID variants. Put even more simply, India — and in particular Prime Minister Narendra Modi and the country’s central government, which is controlled by Modi’s BJP party — tried to get back to normal prematurely, and the country is now paying an enormous price for turning its back on the coronavirus.
It all started, according to Indian health care journalist Vikas Dandekar, when India’s impressive-looking quick turnaround from the first wave “raised false hopes that the virus had run out of steam in India and the country would be spared a second wave”:
Virologists, modeling experts, and prominent epidemiologists appeared on TV shows to suggest that herd immunity may have kicked in, with testing in some cities showing the existence of anti-Covid antibodies in up to half of communities. Some professed that Indians have stronger-than-average immune systems, or they may be spared from COVID-19 by cross protection from other infectious diseases. A few invoked evolutionary biology and said the virus will not kill all its hosts and endanger its own existence.
Then India’s hyper-nationalism took over. Prime Minister Narendra Modi and senior leaders from his Bharatiya Janata Party, who thrive on overwhelming popularity, took no time to claim victory in the fight against the virus. Election rallies attracted soaring crowds. As Modi and Amit Shah, the two top leaders, brazenly took off their masks during their incessant campaigns, those in the crowds followed and dropped theirs.
Further fueling new cases was Kumbh Mela, a gargantuan confluence of Hindu pilgrims who gathered for a holy dip in the Ganges River. As many as 2.5 million people took part, with scant attention to COVID-19 safety protocols. By the time an avalanche of criticism cut short the festival, the virus had infected thousands of pilgrims, who took it home to their neighborhoods and villages.
Efforts to crank up a badly hobbled economy also added to the spread. Business and manufacturing activities began reopening in May 2020 as ministers projected a V-shaped economic recovery while scientific messaging to keep wearing masks and follow social distancing took a beating. Masks, which had become part of public life in India for most part of 2020, gradually disappeared from faces.
Meanwhile, the country has had a sluggish vaccine rollout — with only 2 percent of the population now fully vaccinated — leaving India extremely vulnerable to community transmission, particularly with more transmissible coronavirus variants like B.1.1.7 spreading.
A staggering spike
In mid-February, the country was reporting less than 10,000 COVID cases and 100 deaths a day. An exponential explosion has followed. India reported more than 400,000 new COVID-19 infections in a 24-hour period on Saturday, setting another new world record in daily cases.
The number of people who have been killed by COVID-19 in India is now over 211,000. At least 30 percent of those deaths have come in the last two months, and the country is now recording over 3,300 new deaths every day. India now accounts for more than a third of the world’s current cases, and nearly 40 percent of new cases reportedly globally of the last few months.
And all of those numbers and calculations are based on the government’s official data, which experts agree is a severe undercount.
India’s slow, dysfunctional vaccine rollout — despite being the world’s biggest vaccine producer
Thus far, India’s mass-vaccination efforts have not gone well — which is one of the primary reasons it was left vulnerable for the current wave of cases. Two vaccines are currently available in the country, AstraZeneca’s and one developed by India’s own Bharat Biotech. Both are two-dose vaccines, and manufactured in India. Nearly 11 percent of the country’s almost 1.4 billion residents have gotten at least one dose of a COVID vaccine — which offers some protection against infection — but just over 2 percent of the population has received a second dose. The country opened up eligibility for the vaccine to all adults on May 1, but that may simply worsen another problem:
There isn’t enough vaccine supply
That’s despite India being the world’s largest supplier of vaccines, as the Atlantic’s Yasmeen Serhan recently explained:
India’s role as a major pharmaceutical producer has been spotlighted during the pandemic; it has provided 20 percent of the world’s generic drugs as well as more than 60 percent of the world’s vaccines, despite having inoculated just 1 percent of its own population against COVID-19.* The country has the capacity to manufacture 70 million doses a month, but even with all of those doses directed toward its domestic needs, they’re not enough to meet the overwhelming demand. At present, India is administering some 3 million doses a day. To protect its population of 1.4 billion, [University of Michigan biostatician and epidemiologist Bhramar] Mukherjee said that rate would need to increase threefold.
Multiple states in India reportedly ran out of vaccine ahead of the weekend, forcing the temporary closure of many vaccination sites.
The U.S. and other foreign governments have begun — too late, according to may critics — trying to help bolster India’s vaccine supply and vaccine-production efforts, but it’s not clear how quickly that will result in actual vaccinations.
The shortage isn’t the only problem
On top of everything else, the Indian Express reported earlier this week that India’s efforts to actually get shots in arms has been plagued with issues at the state and local level:
As India tries to accelerate its massive vaccination programme in the middle of a devastating second Covid-19 wave, ground reports from states indicate a complex set of problems ranging from shortage of doses to glitches on the registration portal to panic and fear of the vaccines running out. If the initial weeks of vaccination saw a general reluctance among the public, the severity of the pandemic’s second wave has forced them to flock to vaccination centres, flouting the very rules meant to keep them safe. And to top it off, the [government] will open vaccination to everyone above the age of 18 from May 1, even as [hundreds of thousands] of people in the 45-60 and above 60 high-priority age groups still await the jab.
As one example, a combination of limited vaccine supply and mass-scheduling error prompted chaos at one of the main vaccination centers in the southern Indian city of Thiruvananthapuram last Monday, per the Express:
[A]t the Jimmy George Indoor Stadium[,] COVID-19 protocols were blatantly violated as hundreds of people, many of them above 60 years of age with comorbidities, flocked to the centre from 7 am to get a shot. The bizarre reason for the crowd was that a majority of them had been provided the same time-slot online. With no access to drinking water or seating, at least three persons fainted in the queue and had to be admitted to hospitals.
On Wednesday, after registration for people aged 18-44 to schedule vaccinations was opened up, the central government web portal and a major app used for booking appointments both briefly crashed under the demand.
Another issue: almost half of the population of India doesn’t have internet access.
India’s government played politics with its vaccines — and lost
At the Financial Times, Gideon Rachman recently argued that vaccine nationalism appears to have blown up in India and Modi’s face: the government failed to place timely orders with Indian vaccine manufacturers; it dragged its feet on authorizing foreign vaccines while promoting one designed in India; and vaccine diplomacy concerns, both as a point of national pride and competition with rival power China, led the government to export vaccines it clearly should have been keeping more of that supply and distributing it to its own citizens instead.
There has also been backlash over the central government allowing India’s pharmaceutical companies to charge state governments and private hospitals for vaccines administered to people under the age of 45, and set their own prices, which led to a partial walk-back from one of the companies on Monday.
How big a role are COVID variants playing in the size and severity of the wave?
As is the case in every major new COVID outbreak around the world, there has been a lot of attention on how coronavirus variants might be fueling the skyrocketing number of cases in India — and in particular, the B.1.617 variant which originated in the country. The other variant being detected in genetic surveillance of India cases is the better known B.1.1.7 variant which originated in the U.K., is believed to be more transmissible, and has been taking hold in the U.S. and many other countries. Both are spreading in India, albeit not universally, according to available data — and the variants are likely making it easier for the coronavirus to spread there. How much, and why, is not yet fully clear.
B.1.617 has been referred to as a “double mutant,” since the variant (or rather, one of the three versions of the variant which have been detected) has two worrying mutations which could be making it more dangerous. One mutation likely makes B.1.617 more transmissible, similar to B.1.1.7. The other is the same mutation found in the B.1.351 South Africa variant which scientists believe has a minor impact on vaccine efficacy.
First of all, every variant could be called a multiple mutant, since numerous mutations are normal. So the “double mutant” description for B.1.617, which sounds sort of scary, is a bit of a misnomer. Second, and more importantly, there just isn’t enough evidence to support the conclusion that B.1.617 is fueling the outbreak in India, or, as some have been worrying, better able to break through the protection provided the COVID vaccines which have been administered in the country, or better able to reinfect people who have antibodies from a previous coronavirus infection. Thus far, the available data on so-called “breakthrough infections” in India — real-world COVID cases among fully vaccinated people — indicates that only a fraction of a percent (.02 to .04 percent) of fully vaccinated people there have caught COVID.
Unfortunately, for a variety of not-great reasons, there isn’t enough genomic sequencing currently being done of cases in India to get a more complete picture of how prevalent the variants have become, as the New York Times emphasized on Tuesday:
So far the evidence is inconclusive, and researchers caution that other factors could explain the viciousness of the outbreak[.] … Still, the presence of the variant could complicate the taming of India’s Covid-19 disaster. “The current wave of Covid has a different clinical behavior,” said Dr. Sujay Shad, a senior cardiac surgeon at Sir Ganga Ram Hospital, where two of the doctors needed supplemental oxygen to recover. “It’s affecting young adults. It’s affecting families. It’s a new thing altogether. Two-month-old babies are getting infected.” …
“While it’s almost certainly true B.1.617 is playing a role, it’s unclear how much it’s contributing directly to the surge and how that compares to other circulating variants, especially B.1.1.7,” said Kristian Andersen, a virologist at the Scripps Research Institute in San Diego.
White House announces travel restrictions
The U.S. will begin restricting travel from India next week in an effort to prevent the spread of the coronavirus, the White House announced Friday. The restrictions, which will go into place Tuesday, May 4, will ban entry to the U.S. for people who have been in India over the previous 14 days, CNN reports — though not everyone:
The policy will not apply to American citizens, lawful permanent residents or other people with exemptions. As with all international travelers, individuals who fit that criteria traveling from India must still test negative prior to leaving the country, quarantine if they have not been vaccinated and test negative again upon reentering the US from India. The restrictions also do not apply to humanitarian workers.
That policy is similar to the restrictions currently in place for travelers who have been in the E.U. and Brazil. Numerous other countries have already restricted travel from India, including the U.K. and Canada.
Nearly 100 vaccination centers in Mumbai to close due to vaccine shortage
The city’s municipal government announced the closure of 94 vaccination centers on Friday, citing the lack of vaccine supply, and said the closures would only last through Sunday. Only 26.7 million people — about 2 percent of India’s population of nearly 1.4 billion — have been fully vaccinated as of the end of the week — though 152 million doses have been administered nationwide. Residents of New Delhi have also been asked not to show up for vaccinations on Saturday due to the lack of supply there. Reuters reports that several states in India have run out of vaccine doses.
This post has been updated.