(NYTIMES) NEW DELHI • A lethal, fast-paced second wave of the coronavirus pandemic has brought India's healthcare system to the verge of collapse and is putting millions of lives and livelihoods at risk.
On Sunday and Monday, the country recorded more than 270,000 and 259,000 Covid-19 cases, respectively, a staggering increase from about 11,000 cases a day in the second week of February. Reported coronavirus infections shot up from about 20,000 a day in mid-March to more than 200,000 by the middle of this month.
The newspapers and social media are scrolls of horror and failure of the healthcare system. There are reports of lines of ambulances with patients waiting outside the largest Covid-19 facility in Ahmedabad in the western state of Gujarat because ventilator beds and oxygen had run out.
On Friday, in the northern city of Lucknow, 65-year-old journalist Vinay Srivastava shared his falling oxygen levels on Twitter, tagging government authorities for help. Overburdened hospitals and laboratories wouldn't take calls from his family.
The last tweet from Mr Srivastava's account described his oxygen saturation level at 52, way below the 95 per cent which is considered normal. Nobody helped. He died on Saturday.
At a crematorium in the central city of Bhopal, residents said they had not seen so many cremations since 1984 when a gas leak from a Union Carbide pesticide plant in the city killed around 5,000 people.
On Tuesday at 11am in Delhi, the national capital with more than 18 million people, only 40 intensive care unit (ICU) beds were available for Covid-19 patients.
India has had a total of 15.3 million reported coronavirus cases to date, with reported deaths to date of 180,000 people. A survey funded by the leading government body for medical research indicated that there were roughly 30 infections corresponding to each reported case.
Most reports about the collapsing healthcare system are from major Indian cities. Little is known about the devastation in rural India, where about 70 per cent of India's 1.3 billion people live and where there are far fewer hospital beds and medical personnel. Federal officials have acknowledged that the pandemic is shifting towards smaller cities and rural areas.
Reasons for the surge
How did things change so dramatically between March and this month?
India's rapid slide into this unprecedented crisis is a direct result of complacency and lack of preparation by the government. As the number of cases dropped significantly in mid-February, the Indian government and various policymakers, cheered on by a pliant, triumphalist media, prematurely declared victory over the pandemic.
By early last month, senior government ministers were speaking about the endgame of the pandemic in India.
Cricket matches where tens of thousands of spectators filled stadiums were allowed and movie theatres were reopened. The government did nothing to prevent enormous religious gatherings such as the ongoing Kumbh Mela, a festival in Haridwar in the northern state of Uttarakhand, where millions of Hindus gather for a dip in the River Ganges. Not surprisingly, Covid-19 cases in Haridwar have soared.
India proceeded with elections in five states in multiple phases over a month. And one of the most politically charged contests unfolded in West Bengal, where the polls are being held in eight phases between March and late this month.
Despite the rising number of cases, numerous public rallies were held, with tens of thousands of people cramped together without masks. Although precise data on the correlation between political campaigning and the Covid-19 spike is not available, the number of cases in West Bengal increased tenfold from early to the middle of this month - several times the rates in the crowded cities of Mumbai and Delhi.
The mass political, religious and sports events, which are extensively covered by the Indian media, sent mixed messages about the seriousness of the pandemic.
Impatience to get back to pre-Covid-19 lives made things worse. Indians started mixing widely and playing down the threat also because there is an unfounded sense among many of them that exposure to pollution and microbes had endowed them with superior immunity.
It was inevitable that the virus would roar back. Indians turned out to be as susceptible to Covid-19 as everyone else.
I was one of the researchers for the world's largest Covid-19 contact tracing study last year, covering over 660,000 people in two southern Indian states. We found that an early lockdown - it began when there were fewer than 1,000 reported cases - had kept the virus under control.
The risk factors
The risk of getting infected through exposure to someone with the coronavirus is no different in India. The proportion of people who died after a Covid-19 diagnosis is lower in India compared with many other countries. But that is simply because 65 per cent of Indians are under 35 years old.
Indians with Covid-19 aged 40 to 70 were more likely to have died in India because of the high prevalence of comorbidities like hypertension, diabetes and respiratory disorders.
In our study, Covid-19 patients in their 40s in India were twice as likely to die as those in the corresponding age group in the United States. The rate was 75 per cent higher in India than in the United States when we compared patients in their 50s.
The first wave of Covid-19 was concentrated in poor urban areas, from where it dispersed to rural population centres. Although there is no hard data on the socioeconomic status of those infected during the second wave, cases now seem to have reached the middle class and rural India.
Many Indian states, including Delhi and Maharashtra, have put in place degrees of lockdowns and curfews. India's drive to vaccinate its citizens is being threatened by supply shortages. By Tuesday, despite widening vaccine eligibility to those above 45 years old, only 1.3 per cent of India's population had been fully vaccinated against Covid-19.
The rate of vaccination slowed down in the past week and even stopped in some states because of lack of supply. At the current vaccination rate, it will take till the end of 2022 to fully vaccinate 70 per cent of the Indian population, the approximate level needed for achieving herd immunity.
India urgently needs investments to increase its vaccine production capacity to over 12 million doses a day. If the country achieves that, it can vaccinate 70 per cent of its population in six months.
Finally, there is the uncertainty introduced by new variants and, with them, the risk of re-infections that might not be stopped by the vaccines. There is anecdotal evidence that the new wave of Covid-19 cases in India is attacking a younger population, including children, and resulting in more rapid disease progression than seen earlier.
There is need for systematic evidence to link the upswing in cases and easier transmissibility and lethality of novel variants.
One variant - B1617 - that may have originated in India is spreading widely and has been found in other countries.
Can India get out of the current situation? It no longer has the option of another national lockdown because of the
crushing effect on the economy, but more local and state lockdowns are likely.
Indians will have to self-protect and the Indian government needs to urgently send out consistent messages about the seriousness of the disease.
The Indian government needs to emphasise the mandatory use of masks and quickly move to ban all mass gatherings.
Without consistent messaging and a science-led approach from the government, India risks giving back the hard-won gains made through the nationwide lockdown a year ago.
The unforgiving virus must be denied opportunities to transmit.
• Ramanan Laxminarayan is an economist and an epidemiologist. He is the director of the Centre for Disease Dynamics, Economics & Policy in Washington and a senior research scholar at Princeton.