It is perhaps inaccurate to talk about how the covid-19 pandemic is affecting India, for that would pervert any commentary about covid-19 in a country the size of a continent. As it is playing out, it is a miscellany of pandemics—an agglomeration of peaks and plateaus, peaking and ebbing differently, as the virus washes over a large landmasses and its various populations. There is nothing uniform about the pandemic in India, a confederation of 28 states and 8 union territories, with major unevenness across states, in every healthcare metric conceivable.
For instance, India’s largest state, Uttar Pradesh, has roughly the population of Brazil and its smallest state, Sikkim, has a population similar to Bhutan’s. India’s richer states like Goa have a GDP per capita comparable to that of Jordan, while Bihar’s is similar to that of Haiti.1
There are 1.154 million doctors registered with the Medical Council of India and the state medical councils, which gives us approximately 86 doctors per 100,000 persons.2 Only 10 percent of these are in public hospitals, 90 percent are in the private sector. Poorer states have a grave shortage of trained healthcare personnel with Uttar Pradesh’s population of 200 million served by only 38 doctors per 100,000 persons. Bihar has 37 doctors per 100,000 persons, Chhattisgarh 34 per 100,000, and Jharkhand 13 per 100,000. As the locus of the pandemic changes, outcomes are going to be vastly different for different states and different regions within those states. Thus, in our view, in a country of 1.3 billion, it is ill-considered to claim success while announcing low deaths per million or high tests per million for the entire country: a more granular audit should be presented.
There have been initial hopes followed by disappointments. Kerala, India’s most literate state, with health outcomes comparable to that of some upper-middle-income (and high-income countries) mounted an astonishing response in the early days. Using its strong grassroots networks to test, trace and isolate extensively, Kerala brought down its case count dramatically. In May there were days when it reported no new cases.3 But now, infections are surging. From the index case, it took 110 days for Kerala to report its first thousand cases. In mid-July, there were 800 infections a day being reported. On 1 August, Kerala’s caseload had gone beyond 24,000, with 82 reported deaths. More than 170,000 people were in quarantine, at home and in hospitals.4
So, is the virus an inescapable nemesis in India’s dense clusters? The average per capita living space in India in rural areas is 112.5 square feet and 127.2 for urban areas.5 In Mumbai, the average living space per capita is 48 square feet, smaller than an American prison cell. How does one advocate frequent hand-washing, when millions in these clusters do not have access to piped water or soap?
In spite of this there have also been some remarkable success stories, such as in Dharavi, Asia’s largest slum, in the middle of Mumbai. About a million people live in Dharavi, crammed into an area of 2.1 square kilometres. Eight to ten people live together in poorly ventilated dwellings. 80% of the residents use community toilets. Homes and small factories are co-terminus, sometimes in the same building. Physical distancing and isolation are well-nigh unthinkable. The first case of covid-19 in Dharavi was reported in April, around the time New York City was peaking, and grim analogies of large destructive woodland fires filled the newspapers.6 However, on the day of writing this piece, only two individuals have tested positive in the entire slum cluster. Of the 2513 covid patients recorded in the slum 2168 are reported to have recovered, and there are only 113 active cases.
Dharavi’s extraordinary covid effort was pivoted on daily door-to-door screening, unfettered testing, and aggressive hospitalisation and isolation in nearby facilities. Fever camps came up; mobile vans were moved around to provide digital X-ray facilities.7 The local municipal body employed very harsh containment measures, which were possible by providing free food to a large, contained, out-of-work population at their doorstep. The “Dharavi Formula” is now being replicated in hotspots around the country. Recently the WHO Director-General, Tedros Adhanom Ghebreyesus, during a virtual press conference in Geneva, cited Dharavi as a noteworthy example of an area that could be brought back under control even if the outbreak was very intense.8 That said, a recent sero-surveillance survey conducted by the Mumbai municipal corporation and the Tata Institute of Fundamental Research (TIFR) in the first week of July found that 57% of the samples from other slums in Mumbai had covid-19 antibodies. The municipal corporation sees this as a vindication of its containment strategies. If indeed it is containment or a variation of the host-pathogen interaction that has left these slums largely unaffected, is an unanswered question. Nowhere in the world has such a high prevalence of covid-19 antibodies been demonstrated.
Most observers have been perplexed by the low covid case fatality rate in South Asia and South-East Asia. SARS-COV2 has not ravaged the metropolises of India quite in the manner of New York, and London. There has been some commentary on whether this is an illusion, or whether the data have been uncounted or measured inaccurately (due to political pressure).
On 30 July, the total number of infections in India crossed 1.5 million, with more than 50,000 new infections registered in the last 24 hours. The total fatalities now are more than 35,000. It seems likely that India will end up with the most cases in the world. Perhaps the greatest challenge for India will be to create enough hospital beds with high-flow oxygen capacity in the weeks ahead when the pandemic will inescapably spread deeper. Hospitals and care centres are already consuming up to 1,300 tonnes of oxygen every day, compared to 900 tonnes prior to March. India now claims to have some 130,000 oxygen supported beds in more than 3,000 dedicated covid-19 hospitals and care units. What has not been revealed is how many of these have on-site liquid oxygen reservoirs or cylinder stores supplying piped oxygen to patients. There are state-run hospitals in the cities that lack sufficient piped oxygen and are reliant on cylinders to keep their patients alive. In smaller towns and rural areas this dearth of high flow, piped oxygen supplies will be devastating and will cause many preventable deaths. As the epidemic unfurls, this is going to present a major problem. India has some trying times ahead.
Ambarish Satwik, Consultant, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi, India
Samiran Nundy, Emeritus Consultant, Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
Competing interests: None declared