India is in its darkest days of the pandemic, but there may be still darker days to come. With one in three new infections globally occurring in the country, India’s astronomic surge in cases — more than 3 lakh daily — is propelling the global pandemic, and represents a grave threat to the economic and social well-being of the Indian people. The political leaders, who have been too slow and largely failed to take the outbreak seriously, are now coming to realise the gravity of the task at hand. Lockdowns are spreading, but always one step behind the virus. Given the catastrophic state of affairs, effective intervention will require much more rigorous and extensive action.
A data gap
It is difficult to grasp the true scope of this crisis. New Delhi’s test positivity rate — the rate at which people getting tested for coronavirus receive positive results — recently climbed above 30% . If it takes three tests to find one positive patient, it means that we are likely missing many, many infections. Indeed, one would not be surprised if the true number of infections was now above 10 lakh daily. And we can see it in all those undocumented deaths. While the official statistics suggest 2,000 deaths daily, the true number again is much higher. One crematorium in New Delhi has gone from managing 20 bodies daily to 100; the constant running of the furnaces has caused its steel chimneys to melt.
Premature celebration
How did India find itself in this predicament? Certainly, the country faced many challenges in controlling the coronavirus, including the second largest population in the world, and one spread over an enormous, geographically and socially diverse country comprising both very rural areas and sprawling cities. But India’s leaders have made a very difficult situation worse. Early this year, daily new infections dropped to less than 10,000 — a remarkable achievement, driven in part by successful efforts to enforce social distancing and other public health measures. India began to roll out homegrown vaccines to much fanfare. Bharatiya Janata Party President J.P. Nadda declared that Prime Minister Modi had “saved the country,” comparing India’s performance under Modi favourably to that of the United States.
But this premature celebration has ushered in a nightmare. The resumption of large, in-person political rallies and other large gatherings are part of the fuel that has caused COVID-19 to explode. The Prime Minister recently declared, “I can see a sea of masses” at a rally in West Bengal, apparently oblivious to the grave risk that such a sea poses to his supporters. The government also took almost no steps to limit the risk posed by the Kumbh Mela festival , ironically claiming that infection precautions would present too great a threat to crowd safety. As a result, the Kumbh Mela has resulted in thousands of positive tests, including several sadhus and former King Gyanendra of Nepal , with many thousands of infections sure to go undetected as pilgrims return to their home communities and expose their families and neighbours.
Control strategies
The virus has taken advantage of the overconfidence of the government over the past months, making matters worse. Viruses mutate constantly, but it is when they are allowed to spread unchecked through large populations that more infectious and more deadly variants become established and change the dynamics of outbreaks. India is now faced with managing a renewed epidemic driven at least in part by the B1.617 “double mutant” strain of SARS-CoV-2 , with similar mutations to more virulent strains found in Brazil and South Africa. At the moment, however, scientists and public health policymakers are drawing on extremely limited data, as far too few cases of infection are being analysed to provide a complete and actionable picture of the spread of variants and their influence on disease dynamics. India must rapidly scale up its genomic surveillance efforts to give scientists and public health researchers the data they need to guide policy decisions.
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How can the astronomical growth of the pandemic in India be brought under control? Short-term targeted lockdowns can help — the kind we are seeing in New Delhi and elsewhere. They will break the chains of transmission and can curb the exponential growth we are seeing across the nation.
A second strategy is expanding access to vaccines although its benefits are likely to take weeks to be felt. Vaccine rollout without massive outreach and support for the complex, the challenging logistics of administering vaccines, and simply broadening eligibility requirements will do little to slow the virus. The lockdowns we are seeing now will almost surely need to be extended beyond a week and will need to be in place until infection numbers start coming down substantially. It is worth remembering that lockdowns exact a terrible economic and social cost and are a strategy of last resort.
Steps to take
So what might we do to minimise the time that cities and regions need to be in lockdown? India needs a surge of testing. Right now, given high test positivity rates, it is clear that the nation is not testing enough. Ideally, India would increase its testing rates several times over, with the goal of getting the positivity rate under 5%. The nation has the capacity to do that many more tests but has not made it enough of a priority.
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We also know that universal mask wearing when people are outside their homes can be enormously helpful in curbing the spread of the disease. Given the crowds of Indian cities and towns and the high rates of infections, universal mask wearing, ideally with high quality masks, is critical and must be mandatory.
And banning all major indoor and outdoor events, including rallies, religious festivals, weddings, and so forth, is essential. If those were to continue, any hope of bringing this outbreak under control would quickly vanish.
Of course, India’s pandemic will finally come to an end when enough Indians are vaccinated — and targeting vaccines now most quickly and effectively can help control the spread of the virus. Whatever strategy India takes to administer vaccines (focus on elderly to save lives, young people to slow spread, etc.), the key is ensuring the country has enough vaccines. Here, the government needs to work with manufacturers like the Serum Institute, identify what is slowing them down, and use the full clout of the Indian government to drive production higher.
Looking forward
India is now suffering the worst days of the pandemic, going through a second wave of coronavirus as a result of poor political choices, poor communications, and neglect of public health principles. For months, too many celebrated that India had “beaten the virus” even though none of us could explain how that could be and why. In this crisis, there is much that individuals can do to protect themselves and their families. But political leaders must do much more. The good news is that we know it can be done, and we know how to do it. Focus on public health measures, improve vaccinations, universal masking, and effective coordination across public health efforts. If we do these things, infections can turn, hospitals can stop being overwhelmed, and life can begin to go back to normal.
Dr. Ashish K. Jha is Dean, Brown University School of Public Health, U.S.
