Robert Yates, Director, Global Health Programme
What is causing this crisis in India?
Perhaps this is the first time in the pandemic we have seen a major health system close to collapsing under the strain of so many people requiring hospital care, although maybe Manaus in Brazil was a similar example. The accounts of people dying in queues as they try to access life-saving care or dying in hospitals which run out of oxygen is terrifying and extremely concerning. The response from the national and state governments has been very mixed.
In many respects, this is a consequence of India’s chronically under-funded health system with just over one per cent of GDP spent on public health financing. The health system is also dominated by large private hospitals which tend to cater for the better off with very little spent on primary healthcare for the poor.
Health is predominantly a state issue in India and so you are likely to see some states performing better than others. We must not forget millions of people also never get near hospitals because of the very inequitable health system, so most people who are suffering are suffering at home or trying to make do by buying medicines at local pharmacies.
It is difficult to be optimistic even though the world is rallying round. Personally, I do not think sending ventilators is going to make a significant difference because of the huge numbers despite the fanfare which will be made. This will save some lives in the short-term but what will make a big difference in the long-term is sending serious quantities of vaccines to India.
Dr Osman Dar, Associate Fellow, Global Health Programme
Is the B1617 variant behind the surge in cases?
The jury is still out. We do not yet know to what extent the B1617 variant is circulating across the whole population relative to other variants. It seems likely though that mutant variants like B1617 are playing some role in driving up infections along with the behavioural and social factors stemming from the relaxation in government control measures in recent months.
How much has the government’s decision to allow mass religious festivals and mass election rallies to go ahead contributed to the spread of COVID-19?
The decisions to allow huge religious festivals such as the Kumbh Mela, where millions of Hindu devotees from across India converged at Haridwar on the banks of the Ganges, to go ahead without any meaningful or enforceable control measures in place will undoubtedly have increased transmission and contributed to the current wave of infections. Not only is transmission greatly increased at the events themselves, but the virus also moves along all the heavily-used public rail and road travel links to and from these festivals and rallies, thus spreading across the country.
A key function of any government is the prioritization and allocation of limited resources to protect the public – the Indian armed forces could well have played a valuable role in supporting the logistics and accelerated rollout of the vaccination programme for example, but this option was neither explored nor tested.
Studies suggest some cities have high levels of antibodies in populations plus there have been large scale vaccination rollouts. Why does that not appear to have mitigated India’s second wave?
India is a land of wide inequalities and discrete populations where social interactions between groups can sometimes be limited – for example in the first wave of the pandemic last year the majority of cases (more than 60 per cent) in Mumbai, one of the worst affected cities in the current wave, were from high density housing in slum-areas – but during the current wave around 90 per cent of new infections are coming from the higher income segment of the population that resides in high-rise and standalone buildings, showcasing the social divide across the city.
So within cities and districts there are groups with a relatively higher seroprevalence – the level of a pathogen in a population – and other discrete groups living nearby who have very low levels. The vast majority of the population across the country is still unvaccinated, have not had a natural infection, and are therefore susceptible to the disease.
This means a country such as India is likely to experience repeated spikes or waves of infections as the pandemic moves through different segments of society unless more stringent control measures are instituted rapidly and the vaccine effort significantly ramped up beyond 60 per cent of population.
Will short lockdowns such as Delhi’s six-day lockdown be enough to curb the spread?
Short lockdowns are unlikely to be effective as these typically need to extend to at least cover the whole period of a disease’s incubation period and a period thereafter to observe the impact – and the trouble with having extended lockdowns in a country such as India is the lack of social protection for the population caught up in a lockdown.
With so many dependent on daily wages to pay bills for food, housing, and utilities, and no government help available, extended lockdowns are not a feasible option. Imagine the civil strife that would erupt if furlough or other social protection payments were not available during the lockdowns across the UK and Europe.
What may well work in India’s situation is targeted measures around specific social behaviours and risks – for example night-time curfews and limiting alcohol sales to reduce social interactions and consumption in public or social settings indoors, such as nightclubs or bars. These have been implemented successfully in other countries where social protection systems are also lacking such as South Africa.
Dr Mishal Khan, Associate Fellow, Global Health Programme
How do you think other countries in the region will fare?
The rapid rise of cases in India leading to a huge number of avoidable deaths highlights how quickly situations can deteriorate. Neighbouring countries, such as Pakistan, Bangladesh, and Indonesia have many of the conditions that could result in similar situations – such as already over-burdened health systems, insufficient vaccinations, large populations unable to physically distance, and difficulties in limiting religious congregations.
Gareth Price, Senior Research Fellow, Asia-Pacific Programme
What is the likely impact of the current crisis on India’s politics?
The seeming breakdown of a country’s healthcare system would, intuitively, have a political impact but this is not necessarily the case in India. First, the central government’s supporters in the media are keen not to ‘politicize’ what is an ongoing tragedy, except when it is taking place in opposition-controlled states – India is a federal government and healthcare is the responsibility of state rather than central government.
Second, a clear effort is underway to downplay the extent of the crisis. Numerous reports have noted the number of bodies being cremated in certain districts far exceeds the official death count. Third, India’s public health messaging has led many to view those who contract COVID-19 as being somehow at fault, excusing the government’s responsibility.
But the counter argument is that if the government took credit for India’s earlier response to the pandemic and celebrated India as being ‘the pharmacy of the world’ then when neither condition is true – India has not officially banned exports but it has stopped exporting vaccines – logically it should take responsibility.
Having said all that, none of this changes the fundamental rule of Indian politics in recent years which is that if the opposition is divided, the BJP wins. When it unites, the BJP loses. If COVID-19 is to have a political impact, it would be in changing the calculus of non-BJP parties.