Can India win the fight against deadly coronavirus?

Despite measures, worries are mounting that many factors stack the odds against effective containment

The number of confirmed coronavirus cases in India has been growing at a rate seen at the early stages in other countries where there was subsequently an exponential rise in infections in a matter of weeks.

As a result, worries are beginning to mount whether India will also witness a significant outbreak in the days ahead. This is despite the sweeping measures put in place by governments at the Centre and in the states. In a televised speech on the evening of March 19, Prime Minister Narendra Modi urged people not to leave their homes unless necessary for the next few weeks.

While India placed travel restrictions relatively early in the spread of Covid-19, and several states moved quickly to shutter public places, the country’s high population density (and the associated difficulty in practising social distancing), overburdened public health infrastructure, high prevalence of non-communicable diseases (NCDs) and the prospect of transmission from younger people to the elderly in joint families all stack the odds against effective containment.

The number of people in India who have tested positive for Covid-19 has nearly doubled to 283 in three days. Seven countries have thus far had more than 10,000 confirmed cases of Covid-19, and it took all of them just 13-19 days to go from 100 reported cases to 10,000, according to the World Health Organization (WHO).

“We have to assume that the worst that happened in other countries will also happen here,” says T Jacob John, a former professor of virology at Christian Medical College in Vellore, Tamil Nadu.

He is not the only one sceptical of drawing comfort from the limited number of reported Covid-19 cases in India. “There is no reason to believe the trajectory of the disease will be any different in India,” says Ramanan Laxminarayan, director of Washington, DC-based Center for Disease Dynamics, Economics & Policy.

Though an Indian Council of Medical Research (ICMR) study has ruled out community transmission—in which someone who has not travelled abroad, and has not been exposed to a Covid-19 patient, tests positive—till now, Laxminarayan says the ICMR’s sample size of 830 is too small for a country of India’s size.

“Absence of evidence is not evidence of absence,” he said. On March 18, a Rampur resident who had travelled by train from Delhi to Chennai six days earlier in search of a job, tested positive in Tamil Nadu.

Since the man had no history of foreign travel or known contact with an infected person, authorities in the state said it could be a case of local transmission.

If true, it would be India’s first. On Saturday, a woman in Pune who had not travelled abroad was confirmed to have tested positive. It’s not clear yet if she had met someone with a foreign travel history.

India has come in for praise for being quick to restrict travel from other countries and for tracking down those who came in contact with Covid-19 patients.

“But where we dropped the ball is testing,” says Laxminarayan. As of March 20, around 14,500 individuals had been tested in India, according to the ICMR. The same day, the government agreed to expand its testing beyond those who have had international travel; contacts of those who tested positive; and healthcare workers, all of whom have to exhibit symptoms to be tested.

Now, even asymptomatic contacts of a confirmed case and those hospitalised with severe acute respiratory illness will be tested. Hospitals also have to report pneumonia patients for testing. Adding to India’s woes are the reckless behaviour of some who are at risk. Kanika Kapoor, a Bollywood singer, went to a party in Lucknow days after returning from London, instead of being in selfisolation. She later tested positive for Covid-19.

Also at the party were former Rajasthan Chief Minister Vasundhara Raje and her son Dushyant Singh, a member of the Lok Sabha. Singh then attended Parliament and a breakfast meeting hosted by President Ram Nath Kovind. Raje, Singh and other politicians who came in contact with them have now quarantined themselves at home.

The Lucknow police have lodged a case against Kapoor for negligence. A large Covid-19 outbreak can challenge an already under-equipped healthcare system in India. The country only has nine beds for every 10,000 people, compared with more than four times that many in China.

Around 20% of those infected with the coronavirus need to be hospitalised, explains V Ravi, professor of neurovirology at the National Institute of Mental Health and Neurosciences. “Other countries have had a problem treating severe cases of Covid-19. So will India.”

India also has to contend with the problem of high population density. There are 455 people per sq km, compared with 148 in China, 205 in Italy and 50 in Iran, according to the World Bank.

China, Italy and Iran have reported the highest number of Covid-19 cases. The other risk factor, according to D Prabhakaran, vice-president for research and policy at the Public Health Foundation of India (PHFI), is the high number of people with NCDs such as cardiovascular diseases and diabetes. “These are risk factors for mortality among older people with Covid-19.”

One in every four deaths in India in 2016 was because of heart conditions, according to a study by the ICMR, the PHFI and the Institute for Health Metrics and Evaluation. Moreover, one in every eight Indians aged 50 and above is diabetic, showed a Union government survey conducted between 2015 and 2019.

India has so far seen four deaths, which puts its fatality rate at 1.4%, while Italy’s is as high as 8.3%. That means more than 8 out of every 100 infected people have died—an alarming statistic.

India was among the last major countries to experience an outbreak of Covid-19. So while it has had a good head start in preparing itself to face the challenge, the next couple of weeks will prove crucial in its battle against the invisible enemy.