India Is in Denial about the COVID Crisis

The Indian monsoon season is in full swing, drenching the streets of Mumbai and flooding the plains of Bihar. But dark clouds of another kind—disease, hunger and death—are also gathering fast.

India is now ahead of all other countries in terms of the number of new recorded COVID-19 cases per day—close to 70,000 in mid-August. That’s about one fourth of world-wide new cases. Only two countries are anywhere close: Brazil and the United States; and India has lagged behind those two countries in achieving a reduction in daily cases.

Further, recorded cases in India are likely to be a small fraction of all COVID-19 infections. That could be true in many countries, but the ratio of infections to recorded cases seems particularly large in India—at least 20:1, judging from two recent serological surveys, in Delhi and Mumbai respectively. This would mean that India already had more than 50 million COVID-19 infections, compared with a recorded figure of 2.5 million.

The silver lining is that, for reasons that are as yet unclear, COVID-19 mortality in India seems relatively low. The same surveys suggest that the infection-fatality rate (IFR) may be as low as one per thousand. If so, India may not be heading towards a major mortality crisis, or rather a major crisis of COVID-19 mortality, at least relative to normal levels of mortality. COVID-19 deaths so far add up to less than 1 percent of annual deaths from all causes in India. Per million population, there have been just 38 so far, compared with more than 500 in the US.

Overall mortality may spike, however, for two reasons. First, routine health services have been massively displaced by COVID-19. So far, COVID-19 infections were heavily concentrated in large cities located in India’s more prosperous states: Delhi, Mumbai, Chennai, among others. The preparedness of the health system is much higher there than elsewhere. But recorded cases are now rising fast in India’s poorer states, where health services are very fragile. As the COVID-19 crisis absorbs their meager resources, many public health centers have stopped providing routine services. Even child immunization has been discontinued for months in many states.

Consider the state of Bihar. If Bihar were a separate country, it would be one of the very poorest countries in the world, with a population of more than 100 million. About half of all children in Bihar are stunted. COVID-19 was late to reach Bihar, but recorded cases have recently crossed 100,000 and are now rising at 3 to 4 percent per day. The state has fewer than 40 doctors per 100,000 population, compared with 90 in India and more than 250 in the US. Firsthand accounts of life in Bihar’s public hospitals paint a grim picture of missing doctors, unattended patients, broken equipment and stray dogs. Where are people with routine health problems supposed to go?

The other reason for a possible mortality spike is that India’s prolonged national lockdown (from late March until unlock phases began in June) has destroyed millions of people’s livelihoods. Local lockdowns continue in many states and are likely to persist off and on for months. Unlike affluent countries, India has very little to show by way of a social security system, except for food subsidies and some relief work under the National Rural Employment Guarantee Act. The employment crisis has already hit poor households really hard: recent surveys by Dalberg, Azim Premji University, the Center for the Study of Developing Societies (CSDS) and others reveal extreme food insecurity during and after the lockdown. Just to cite one, 78 percent of the 25,000 respondents in the nationwide CSDS survey said that they had found it “quite difficult” or “very difficult” to feed their families during the lockdown. Acute food insecurity is very likely to translate into higher mortality. For children, it also means lasting damage from malnutrition.

To invoke Bihar again, more than half of the workforce there consists of casual laborers who live on the margin of subsistence at the best of times. A recent survey of some 20,000 returning migrant workers found that 60 percent were unable to ensure two square meals for all members of the family. With the local economy in the doldrums, except for farming, casual workers are heading for a prolonged period of underemployment and hunger. For good measure, Bihar is affected by devastating floods, as often happens at this time of the year. Yet the state government seems more preoccupied with the coming assembly elections than with these multiple crises.

The situation is not much better in other poverty-stricken states of India such as Jharkhand, Uttar Pradesh and West Bengal. With tax revenue a fraction of normal levels, state governments are finding it difficult to provide more than symbolic relief. Alas, the central government is doing little to help them. It did launch some limited relief measures during the national lockdown, such as free food-grain rations of five kilograms per person per month for two thirds of India’s population. But now it seems to have lost interest and left it to the state governments to handle the crisis.

In this as in other domains, the Indian government seems more focused on public relations than enlightened action. For a long time, it forcefully denied any “community transmission” of COVID-19, even as recorded cases were counted in millions. When an early analysis of official data exposed the disruption of routine health services, the central government retracted the data. Doctors and nurses critical of the government’s crisis response have been muzzled or harassed, as have many journalists. Muddled statistics are routinely invoked to reassure the public that all is well: the Ministry of Health recently boasted, for instance, that COVID-19 recoveries had “crossed the historic peak of 1.5 million”—a meaningless achievement since COVID-19 has a recovery rate of more than 99 percent in India.

In its hurry to turn India into a viswaguru (world leader), the Modi government seems to have little patience for a humanitarian crisis. Yet denying a crisis is the surest way to make it worse.