What India needs to fight the virus

On Tuesday evening, Prime Minister Narendra Modi ordered 1.3 bn Indians to stay inside their homes for 21 days in an unprecedented bid to stem the spread of the coronavirus in the country.Soon after the first case of the coronavirus arrived in India in late January, India responded with restrictions on flights and screenings at its airports. Yet the country had more than 80,000 arrivals every day, mostly from Europe and the Gulf States, where the virus had spread. And across the country, millions of people live in proximity, in densely populated slums where access to healthcare is poor. The government’s decision to impose the lockdown was necessary to mitigate the inevitable spread of the disease.

I have been working with a group of researchers at multiple institutions in India, Europe and the US to develop a large-scale computer model of the Indian population over many years. As we looked at the situation in India and evidence from other countries, the consequences of a catastrophic situation became more and more apparent.

Studies from China suggest that people with uncontrolled hypertension and diabetes are more likely to experience severe COVID-19 and die from it. About a third of India’s population is hypertensive, and over one in 10 adults are diabetic. Children were less likely to be infected in China, but India has millions of undernourished children, who are more prone to infections. India’s high rates of TB, pneumonia, smoking and poor air quality won’t help when it comes to a respiratory disease.

Some were counting on the summer heat and humidity to bail India out, but there was no evidence that the rising temperature would stop the disease. Our initial estimates showed that 300 to 500 mn Indians were likely to be infected with the coronavirus by the end of July.

Most of the cases would be without symptoms or with mild infections, but about a tenth — 30 to 50 mn — would most likely be severe. Our model predicted that at the outbreak’s peak, even with conservative assumptions, there would be 10 mn patients with severe COVID- 19 disease in India, many of whom would need to be hospitalised.India has fewer than 100,000 intensive-care unit beds and 20,000 ventilators, most of which are only in the large cities.

The scenes where Italian doctors had to choose between multiple patients to determine who would get a ventilator would increase multifold in India’s weak health system. Although the proportion of COVID-19 patients who die has averaged between 2 per cent and 3 per cent globally, they were in places where the health system is better equipped.

India does not have the strong health system and economic resources of COVID-19-affected high-income countries or China’s ability to control population flows in the country. A lockdown was the only option to control the disease. By the time Modi announced the lockdown, India had officially counted about 500 cases of coronavirus infection and estimated 10 deaths because of the contagion. (The official numbers increased on Thursday to 649 infection cases and 13 deaths.) The numbers were so low because testing for the virus has been limited.

Estimates from our group of scientists and others suggest the actual number of infection cases in India is likely to be about 21,000 by now. Our estimates and those from the Indian Council for Medical Research indicate a national lockdown, if adhered to well, could reduce the number of infections at the peak of the pandemic — expected by early May — by 70 to 80 per cent, depending on the degree of compliance with physical distancing. Our estimates suggest that about a million people would still need hospital beds and critical care. Had India not imposed the lockdown, it would have been five million to six million people.

India has four to six weeks before the coronavirus outbreak hits its peak. It is absolutely necessary to use this window of opportunity to create an enormous, affordable and easily available testing infrastructure, intensify efforts to identify the sick, trace contacts and isolate them and prepare for the avalanche. Hygienic quarantine facilities and intensive-care beds must be set up in all state capitals.

New Delhi has to move swiftly, marshal its financial and human resources, and build temporary COVID-19 treatment facilities; procure necessary equipment, including test kits; and buy personal protective equipment, hospital beds, oxygen-flow masks and ventilators. At the same time, it has to train health workers in infection control and safe testing.

If India fails to fill these serious gaps in its capacity, the pandemic will exact a heavy toll. The disease is likely to return later in the year. Many Indians still lack immunity to the coronavirus, although the extent will be known only when surveys are conducted that are able to test the population for antibodies that indicate their exposure to the disease.

On Thursday, India’s finance minister announced a support package of $20.6 bn, which includes direct cash payments, free cooking gas, and food grains and lentils for the poor. Indian government has massive amounts of excess food stocks that could be used quickly to expand the public distribution system.

Medical personnel around the country have complained about lack of protective gear, which should be addressed. Both public and private sectors will have to join forces. The next four weeks are absolutely crucial for India, and the lives and livelihoods of 1.4 bn Indians depend on the work that lies ahead