India is recording its highest ever numbers of COVID-19 cases and deaths each day. Having appeared to recover well from its first wave of infections, the country is now in the grip of a second wave which places it as one of the worst countries in the world in terms of both case and death figures.
There have been over 16 million cases and 185,000 deaths officially recorded from COVID-19 in India at the time of writing. Adjusting for population sizes India is faring far worse than its near neighbours Pakistan, Bangladesh and Nepal and countries such as the US and Russia.(1)
At the start of 2021 India appeared to be doing well. The peak of its first wave was mid-September 2020 when just under 100,000 daily new cases were being reported. By mid-February 2021 this has dropped to under 11,000 new cases per day but since the beginning of March case figures have risen steeply, surpassing those seen in the previous peak. India is currently recording over 300,000 new cases per day and this upward trend is still continuing. A lack of COVID-19 testing capacity across many states in India means that the true cases figures are likely to be even higher.
Likewise the death figures are following a similar upward trend and, although they appear to be lower than many other countries (India is recording 133 deaths per 1 million of the population compared with 1,867 in the UK and 1,749 in the US), with fewer than 25% of deaths medically registered in India even the Indian government acknowledges that the true death figure is much higher. (2) (3)
With a norm of around 80% of deaths happening at home, and many of the dead cremated in open countryside, collating COVID-19 deaths from hospital data and official funeral services is always going to be a severe underestimate. (4)
Background to COVID-19 in India
India’s first case of COVID-19 came on 30 January 2020 in the state of Kerala in a student who had recently returned from Wuhan. (5)
At the beginning of the pandemic, the Indian lockdown was one of the world's strictest because of how swift and severe its restrictions were. On 24 March 2020, when the total number of confirmed cases across the country was only 550, Prime Minister Narendra Modi ordered the entire nation to remain confined within their homes with the one exception of essential workers. The announcement was given with just four hours’ notice and saw the closing down of the entire country including all of the transport network. This precipitated a huge humanitarian crisis in a country which relies on millions of rural migrants who found themselves stranded in cities with no work, no food and no money. With no public transport operating many attempted to get back to their villages on bikes or on foot often facing journeys of hundreds of miles. It is estimated that up to 90 million people became stranded during the national lockdown and some did not reach their home villages but died en route from exhaustion. The irony was that during the panic that ensued (because lockdown was so swiftly enforced) large swathes of people had no choice but to congregate in huge crowds as they tried to find food, water and any possible transport thus creating ideal conditions for the virus to spread. (6)
There continues to be limited testing capacity across the country. In the state of Uttar Pradesh for example, India's poorest and most populated state with over 200 million inhabitants, there was only one laboratory able to test for COVID-19 at the start of the pandemic. The state now has 33 laboratories although they are concentrated in the cities.
(7) (8)
On 12 May 2020, when the infection number had risen to 71,000, the Prime Minister adopted a completely different approach to the pandemic telling the nation that they would have to learn to live with the virus and should go back to work. He gave a televised address saying, "Corona will remain part of our lives for a long time but we cannot allow our lives to be confined only around corona.” (9)
In March 2021 India’s health minister announced that the pandemic was in its final stages in India and there was a mood of jubilation. Fewer people were turning up for their vaccinations as they felt there was less urgency if the pandemic was effectively over. (10)
Yet scientists had been warning from mid-February that cases were rising in some states, particularly in Maharashtra which is home to Mumbai, India's largest city. They could see that India was following the same pattern as other countries and would soon be in the grip of a second wave but their warnings were ignored. Prominent Indian epidemiologist Dr Lalit Kant told the BBC at the time: "A false sense of normalcy has swept the country. We cannot afford to drop our guard and we have to be cautious about opening places of mass gatherings. Testing, tracing and isolation has to be again scaled up massively in all states - we cannot wait for things to get worse." (11)
Just weeks later, in April 2021, many parts of the country are re-instigating lockdowns amidst warnings from its hospitals that they are running out of beds, oxygen and drugs. The capital Delhi implemented a six day lockdown from 19 April 2021 but there is no national lockdown, it is up to individual regions to make their own decisions. Hospitals are turning sick people away, not because they don’t care but because they have no resources left with which to treat them.
As of 23 April 2021 the UK shut its border to India. Only UK passport holders or those with residency status will be allowed to enter the UK from India and must quarantine in a designated hotel for 10 days immediately after their arrival. (12)
India’s Vaccination Programme
India has authorised three vaccines - Covishield (their name for the AstraZeneca vaccine which is being manufactured by Serum Institute of India), Covaxin (manufactured by Bharat Biotech Limited, an Indian company) and Russia’s Sputnik V.
India began its vaccination programme in January 2021 and has already vaccinated more than 130 million people. (13)
Initially healthcare and frontline workers were prioritised for vaccination followed by those over age 60 plus people over age 45 who are clinically vulnerable. This alone amounted to more than 250 million people and the hope was to have vaccinated them all by the end of July 2021. (14)
In view of the current situation India has now announced that it wants to vaccinate everybody over the age of 18 India beginning on 1 May 2021. It is not yet clear where all the additional doses of vaccine will come from. The Serum Institute and Bharat Biotech are both struggling to meet demand and the first delivery of Sputnik V from Russia is not expected until the end of May.
Maharashtra state is already turning people away from vaccination centres because they have run out of vaccine.
The government has agreed to finance a £428m grant to the Serum Institute and Bharat Biotech to help them step up vaccine production but the Institute is warning that it will soon run out of the raw materials needed to manufacture the AZ vaccine, a situation not helped by the US’s export bans on such items. (15)
Where has it gone wrong?
Given that India coped with its first wave of infection, and now has the added benefit of vaccinations, why is it struggling to cope now?
By January 2021 COVID-19 appeared to be under control across India. As a result life was allowed to return completely to normal with all shops, markets, schools and businesses open and gatherings such as large weddings and cricket matches with thousands of spectators present all going ahead. At the same time, a combination of major Hindu festivals and enormous political election rallies brought millions of people together. Scant attention was given to measures such as social distancing and mask wearing. Meanwhile, a new variant of the virus first identified in India in October 2020 may be an added driver of infections but it is not clear yet if this is the case.
Millions of Hindu devotees came to the Ganges river (which they believe is scared) in the city of Haridwar to go into the water as part of the Kumbh Mela festival. This festival began on 14 January 2021 and is running for three months. There are no restrictions in place in terms of mask wearing or social distancing and attempts to implement COVID-19 testing during the festival had to be abandoned when they proved unworkable in the face of such large crowds. (16)
The local government of the area is now facing much criticism for allowing the festival to go ahead and not cancelling it before the official end. Instead organisers have told news agencies that they believe the sacredness of the Ganges means the virus cannot exist there. (17)
It is virtually impossible to know how many of the attendees are becoming infected with COVID-19 whilst at the festival. Conservative estimates are in the many thousands. It is fair to assume that the number will be very high and people will be spreading the infection as they travel long distances across the country. It is also probable that with the huge numbers of people attending, the Kumbh Mela is acting as an ongoing super-spreader event. (18)
Many parts of the country have inadequate medical facilities and people struggle to access healthcare in normal times. The opportunity to build up supplies of oxygen, drugs and equipment when the first wave was over was ignored. Likewise, vaccination should have been stepped up when case numbers were low but instead complacency took over. (19)
The “Indian Variant”
Labelling variants as UK, South African, Indian etc is not particularly helpful. It actually means these are the countries where they are first identified rather than where they originated from.
A new strain of the coronavirus was first identified across India in October 2020 and scientists across the world are working to establish if this latest variant, officially called B.1.617, is more infectious and/or more deadly. Although the media is reporting it as a “double mutation” (because it has more than one change) and using emotive language to describe it there is no such term as "double mutation" scientifically. (20)
Scientists have already noted that this latest variant has some changes similar to those identified in other variants but have not yet labelled it as “a variant of concern.” Whilst it is possible that the current vaccines will not be as effective against some or all of the newer variants, it is highly unlikely they will have no effect at all. Research so far suggests that all vaccines retain some effectiveness against all variants although a booster “top-up” vaccination could be rolled out later in the year to offer a higher degree of protection. (21)
In Conclusion
The current COVID-19 crisis in India is multi-factorial in its origins. A combination of resuming normal life too soon, allowing millions of people to attend gatherings and logistical problems with the vaccination programme have caused a perfect storm. Unfortunately, with only piecemeal regional lockdowns in place and huge festivals still going ahead it will be some time before India even reaches the peak of its second wave and the grim footage we see coming out of the country will continue.
