In India, a punishing three-month-long lockdown may be coming to an end, but a relentless increase in coronavirus cases is crushing the health-care system of the world’s second most populous country.
Outside New Delhi’s Lok Nayak hospital, Shubhneet Sethi was checking in on his mother and told a CBC News producer he’s appalled by the poor treatment she’s received in a COVID-19 ward that he says is overwhelmed by the number of patients, with staff unable to help.
“We are witnessing death. We are witnessing the dire situation of the hospital. It doesn’t look good,” said the 30-year-old financial analyst.
Generic drug supply could be at risk
“Our worst fears are coming true,” agreed Madhukar Pai, Canada Research Chair in Translational Epidemiology and Global Health at McGill University in Montreal, who follows public health in India.
“We were all worried about what happens when the epidemic starts hitting low-income countries, and it’s happening now.”
India had been selectively easing lockdown restrictions in certain parts of the country since May and entered the next stage of its phased reopening on June 8, with hotels, restaurants, shopping malls and places of worship being allowed to reopen while movie theatres, bars, gyms international flights and some metro rail travel remain suspended.
Pai says the virus’s impact on the country and the instability it’s creating in some key industries should be especially worrying given the nation’s pivotal role in supplying a lot of the world’s pharmaceuticals.
Prices of some drugs have already risen. Supplies of raw ingredients from China have been interrupted as have the transportation networks that deliver them.
While the largest drug companies are European- and American-owned, they rely heavily on production facilities in India, which supply roughly 20 per cent (by volume) of the world’s exports of generic drugs.
“What happens if India stops manufacturing pharmaceuticals?” said Pai. “The entire world’s supply chain is going to get hit. There is no way the rest of the rich world can get on with normal business as usual.
“We are already worried about that with TB and HIV medicines and malaria medicines.”
Deaths in rural areas can go undocumented
India has seen the number of confirmed cases rise from a little over 42,000 at the start of May to more than 380,000 today, and reported a record 13,500 new COVID-19 cases Friday, with more than 300 deaths in a 24-hour period.
That makes it the country with the fourth-highest number of COVID-19 infections in the world, behind only the U.S., Brazil and Russia.
But those who study public health in the nation of 1.4 billion people say those figures are likely only capturing a modest percentage of all COVID-19 infections.
“The bad news is that we don’t know what’s happening in the rural areas of India,” said University of Toronto epidemiologist Prabhat Jha.
He says migrant workers who work in the country’s large urban areas can return to their rural villages, infect others in their family who then die and are buried without ever being issued a formal death certificate.
Jha was a prominent researcher on the Million Deaths Study, which tracked 14 million Indians over 16 years to better understand the causes of mortality in the country. He says, in an average year, about seven out of 10 deaths in India occur outside the big cities.
In the case of COVID, however, the lion’s share of cases are occurring in the urban areas of Mumbai, Delhi, Chennai and Ahmadabad, which have seen a substantial spike in infections in the past two weeks. Chennai was put under a new lockdown until June 30 after fresh outbreaks in the southern city and surrounding districts this week.
Higher incidence of pre-existing conditions
More than 12,500 people in India have died from the virus to date, but Jha says if there is any good news in India’s COVID experience it’s that its death rate, which Indian health officials say is doubling every 18 days, is rising more slowly than in the worst-affected parts of Europe and the United States, where deaths doubled every five days at the height of the pandemic.
India has a younger population than those regions, but at the same time, Jha says, it also has a higher incidence of heart disease, malnutrition and other conditions that can make people more vulnerable to COVID-19.
“So, it’s a bit of a mystery why the death rate is lower [in India], but that’s of little comfort because the deaths continue to increase,” he said.
“And unlike in Europe or Canada, where deaths have peaked and are coming down, in India, [in the regions] where it’s measured, deaths are continuing to increase.”
Hospital horror stories
Indian media have given prominent coverage to hospital horror stories, such as the case of a 82-year-old Mumbai woman who died as she tried to reach a bathroom cubicle. Her body was reportedly not found for more than a week.
In another case, a 68-year-old-man died after six hospitals denied him admission.
Sethi, whose 54-year-old mother was admitted to a Delhi hospital last week with COVID-19 symptoms, said he and his sister had to make a mad dash across the fiercely congested city to tend to her after hospital staff were nowhere to be found when her oxygen ran low.
Sethi said she called him at 4 a.m., gasping for breath.
“I waited outside the emergency room [to talk to a doctor], but they kept turning me away.”
Arvind Kejriwal, the chief minister of the National Capital Territory of Delhi, told a news conference this week that the city of close to 30 million people will need 150,000 beds by the end of July if its hospitals are to also treat COVID-19 patients from other regions. The current capacity is just 9,000 beds — earmarked for COVID-19 patients by the government.
Earlier this week, the government announced it would convert several hundred old train cars, as well as banquet halls, hotels and other venues, into COVID wards.
‘The government has failed’
At the Nigambodh Ghat, New Delhi’s largest crematorium, anguished families placed the bodies of dead relatives on top of wood pyres or next to large electric furnaces.
“They have taken my father. My father is gone,” wailed Tarun Bushan after watching a team of workers clad in blue hazmat suits place the white shroud containing his father’s body near the opening of one of the facility’s large ovens.
“The government has failed; the infrastructure has failed; everything is failed,” Bushan told CBC producer Murali Krishnan.
Three ovens, along with dozens of wood pyres, now burn well into the evening handling between 30 and 35 COVID victims a day.
WATCH | New Delhi’s largest crematorium struggles to keep up with the rising number of COVID-19 deaths (video contains images of cremation and transport of covered bodies):
Three other facilities in the city are also disposing of the pandemic’s dead.
The spike in cases — and heavy strain on the hospital system — comes just days after India lifted its wide-ranging and strictly enforced lockdown.
India appeared to react relatively early — and decisively — to the pandemic by cutting off international travel in March and imposing a lockdown on all but essential services on March 24.
But in doing so, the government of Prime Minister Narendra Modi came under harsh criticism for displacing millions of migrant workers and day labourers who suddenly found themselves out of work and far from their homes. That led to huge crowds and chaos at transportation hubs as they tried to make their way back to their villages and may have contributed to the spread of the virus.
McGill’s Madhukar Pai says while India’s lockdown no doubt slowed the “explosive” spread of the virus through the vast country, it came at a heavy economic cost.
“You need a certain amount of privilege to survive [a lockdown]. You need a house; you need an income; you need basic necessities of life. But in many low-income countries, there is no such thing.”
He says with the nation now suffering from “lockdown fatigue,” the only way forward is to test people who show symptoms and to then isolate them and their contacts.
India has ramped up of testing in the last two months but is still testing at a far lower rate than many Western nations. It is testing at a rate of about 4,700 tests per million people, according to Our World in Data, a site run by Oxford University and Global Change Data Lab. That compares to about 148,000 per million in Denmark, 80,000 per million in Italy and 60,000 per million in Canada — although testing rates in India vary widely by state from around 1,000 to 27,000 per million, an analysis of state data done by the Indian news site The Wire found.
Pai’s prognosis for India in the weeks ahead is poor.
“There is no way, especially with the lockdown’s lifting. Epidemiologically, I cannot see how the trend will start going down.”