India is now identifying more than 1 million coronavirus cases every three days, with many times more thought to be going unregistered in a vast country where public health surveillance is often poor. Daily deaths exceeded 2,800 on Sunday, but these too are thought to be many times higher.
Epidemiologists and other experts are speculating that several factors have coalesced over the past months to bring India to the point of the world’s worst Covid-19 outbreak.
One idea is that India’s second wave is being driven by highly infectious variants of the virus that causes Covid-19. The so-called “double mutation” or B1617 variant has received significant attention, though virologists note that it does not appear to be the dominant strain across the country, and nowhere near enough samples of the virus have been taken to firmly place the blame on any one variant.
The UK variant is driving infections in parts of India, as well as other mutations that are yet to be studied properly. The best guess of epidemiologists is that these are more infectious than the iterations of the virus that were spreading in the country last year.
“We can say [these variants] are all more infectious based on their behaviour,” Dr Shahid Jameel, a virologist and director of the Trivedi school of biosciences at Ashoka University, told the Guardian last week. “Though in India we have not been able to correlate the mutant variants with the surge, based on what we’ve seen earlier [in the UK and elsewhere], it’s the logical explanation.”
Variants of interest or concern have been circulating in India since at least last December, when cases there were still declining, so they are unlikely to be the only factor driving this renewed outbreak. India had largely relaxed its social distancing and quarantine measures by March – a decision now viewed as a profound political misjudgment.
Official case numbers in India started to decline steeply from September. It could have been an opportunity to gird the country’s healthcare system and build vaccination infrastructure ahead of a larger second wave of the kind that other countries had witnessed, and which many scientists were warning was inevitable.
Instead, the Indian prime minister, Narendra Modi, pressed ahead with election rallies, where he boasted about the size of the crowds, and cricket matches including in a new stadium that bore his name. His Bharatiya Janata party declared India had beaten Covid-19 in a laudatory February resolution.
Events permitted to go ahead included the Kumbh Mela, one of the largest gatherings in the world, which drew millions of pilgrims to the banks of the river Ganges over several weeks, and probably provided no shortage of potential hosts for whatever variants were circulating.
For many Indians, living in crowded slums or forced to work to survive, social distancing is impossible. Yet others, especially middle-class people in larger cities, were able to take Covid-19 precautions last year that helped to slow the spread of the virus. Taking the cue from their leaders, many Indians abandoned these measures through February and March, returning to restaurants, salons and malls. For some, this has been a fatal decision.
Weak health infrastructure
India has many excellent hospitals and medical professionals, but its state healthcare system is one of the most poorly funded in the world, hovering at a little over 1% of GDP. There is less than one doctor for every 1,000 people, and that figure drops further in rural areas and poorer states.
The result is a fragile system built on fewer beds than required and supplies of medical equipment, drugs and oxygen that cannot withstand a surge of cases.
It also means less ability to track the scale of the pandemic. In rural areas especially, most people are thought to die at home, their cause of death unregistered.
India entered the pandemic as the world’s largest producer of vaccines. It continues to produce more than 80m doses a month, but is now being outstripped by China and the US, who made significant investments in their manufacturing last year. India, in contrast, is running into shortages, even though vaccine take-up among Indians has been slower than expected, with about nine in 100 people receiving at least one dose so far.
But owing to its sheer size, vaccinating its way out of the pandemic imminently is out of India’s reach. As of Saturday, there were about 1bn doses administered worldwide. If every single one of those had been used in India, and assuming a two-dose regimen (Johnson & Johnson’s formulation is the only one-dose vaccine so far), the total sum would have been enough to inoculate about 500 million Indians – leaving about 400 million adults still awaiting a shot.