India’s Covid Disaster Exposes the Peril of Complacency

By Chris Kay & PR Sanjay

Governments around the world keep repeating the same mistakes. In a country of 1.4 billion, the consequences are on a whole new scale.

The snaking queue outside Maasaheb Meenatai Thackeray Hospital terrified Mariselvan Thevar. More than 200 people were in line, sagging in the heat as they coughed and wheezed. Some had come hoping to find a dose of coronavirus vaccine, which remains a scarce commodity in India. Others were trying to get their hands on medication, a bed, oxygen—anything.

A 21-year-old engineering student with a tall, lean frame and a patchy beard, Thevar thought he had little choice but to join the growing crowd outside the hospital, a small public facility in suburban Mumbai. His father, Kannan, had been ill for days. At 49, Kannan was far younger than the people who, for most of the pandemic, have experienced the worst outcomes from Covid‑19. Yet Thevar grew increasingly anxious as they waited to be seen; his father was running a high fever, and even slight exertions left him breathless.

With just two overwhelmed doctors working, the hospital was allowing only a trickle of patients to enter its doors. After 10 hours in the baking sun, Thevar and his father were turned away. “The doctors were insisting patients go home, citing a shortage of beds, on the assurance that they will call them,” Thevar said. “They never call back.”

As the virus burns through India, this sense of futility and fear has become commonplace. The country is reporting nearly 400,000 confirmed infections and 4,000 deaths every day, tallies that are certain to be drastic undercounts. In Delhi, public parks have been requisitioned as makeshift crematoriums, with rows of funeral pyres burning where kids once played cricket. Hospital beds and oxygen cylinders are in short supply, as are doctors and nurses. Some researchers predict that the total number of fatalities—currently at 250,000—could top 400,000 by mid-June and then keep climbing.

The crisis in India is horrific on its own terms, generating misery and loss at an enormous scale. It also has worrisome implications for the rest of the globe. Home to the world’s largest vaccine industry and, until remarkably recently, recording only a modest number of coronavirus cases, India was central to international plans to inoculate developing countries by churning out low-cost doses. Instead its exports have largely ceased, with available vials prioritized for domestic use, and there’s no timeline for when they might resume. Meanwhile, an unchecked outbreak in a nation of over a billion citizens creates ideal conditions for new variants to take hold. It’s hard to imagine a more effective way to come up with mutations that might resist current vaccines.

But for Indians, huge numbers of whom are now sick or caring for ailing loved ones, those concerns are secondary to the immediate catastrophe. After being sent away from the hospital, Thevar’s father deteriorated further, struggling through the night to breathe. The student made frantic calls to friends and relatives, trying to find anyone who could help get Kannan a hospital bed. None could. He called about 20 clinics, all of which gave him a version of the same answer: They had no space to spare. Next, Thevar raided his family’s savings, spending 8,000 rupees ($109) to have a private ambulance shuttle his dad around Mumbai, searching fruitlessly for oxygen.

Eventually, Thevar’s luck turned. He managed to get a local politician on the phone, and persuaded him to pull some strings and have his father admitted to a hospital run by a charity. The staff there took Thevar’s number, promising to update him twice a day. Exhausted, he returned home, finally able to rest. Two days after Kannan was admitted, his doctors contacted Thevar with some bad news. The older man had stopped responding to remdesivir injections and had to be put onto a ventilator. A few days later, early in the morning, they called Thevar again. His father was dead.

A few weeks into 2021, the Reserve Bank of India issued a curiously optimistic press release. Straying from monetary policy into epidemiology, the central bank declared that India had beaten Covid, and that, better yet, “soon the winter of our discontent will be a glorious summer.” Of the virus’s curve, the RBI said, India had managed to “bend it like Beckham.” Although he used less florid language, Prime Minister Narendra Modi was similarly bullish. At a digital-only meeting of the World Economic Forum in January, he boasted that he and his compatriots had “saved humanity from a big disaster by containing corona effectively.”

Such statements may seem delusional in retrospect, but the viral numbers did look good at the time. After a surge last September that pushed daily case numbers to almost 100,000, by January new infections had slumped to less than a tenth of that level—a per-capita rate comparable to South Korea’s, which is among the lowest in the industrialized world. Even in Dharavi, a Mumbai slum home to perhaps a million people, an aggressive public-health campaign had kept the virus largely under control. With social distancing restrictions mostly lifted, crowds returned to markets and restaurants, and well-heeled families booked holidays at beach resorts.

Epidemiologists and armchair experts debated a range of theories to explain the decline in infections, as well as India’s relatively low number of deaths among those who did get sick. Many cited the protection afforded by its youthful population, with a median age of just 27. Others suggested the warm climate of South Asia might be slowing viral transmission, or speculated that enough Indians had already been infected to reach some degree of herd immunity. Then there was the so-called hygiene hypothesis: the notion that, in a country of crowded cities and poor sanitation, people are naturally resilient to new diseases.

Some scientists urged caution. For one thing, no one could be sure the figures were correct. India’s testing rates are less than half those in the U.S., and mortality statistics are notoriously unreliable. Even in normal times, about 1 in 5 fatalities are never reported to the authorities, and official records often don’t list a cause of death. In December, the country had detected its first cases of B.1.1.7, the variant initially identified in the U.K., prompting concerns about out-of-control spread.

Yet politicians needed little encouragement to bring life back to normal. Even as infection rates began to rise in February, multiple state elections drew huge, largely unmasked crowds to hear candidates speak. Modi bragged about the size of the rallies he and his right-hand man, Home Minister Amit Shah, had managed to hold ahead of the vote in West Bengal, a densely populated state of more than 90 million people. Officials also encouraged citizens to participate in the Kumbh Mela, a Hindu festival on the banks of the Ganges that is the world’s largest human gathering. Millions did, packing shoulder to shoulder by the edge of the sacred river.

By mid-March, the number of infections reported each day had more than doubled from a month earlier, while India’s vaccine rollout remained sluggish. At the World Health Organization in Geneva, chief scientist Soumya Swaminathan fretted that her home country was ignoring a viral time bomb. “It could take off again at any time,” she said on March 13. “We should not become complacent.” It was already too late.

By April, Ramanan Laxminarayan felt helpless. The founder of the Center for Disease Dynamics, Economics & Policy, a public-health think tank, Laxminarayan was hunkered down at home in Delhi, his phone pinging constantly with messages from friends trying to find oxygen. When a 42-year-old colleague got sick, the hospital where he sought treatment was asking patients to bring their own oxygen supplies. Laxminarayan started getting requests for help even from senior bureaucrats, members of India’s elite who were unaccustomed to wanting for anything. Even they couldn’t find the care they needed.

Furious that so little appeared to have been done to prepare for a new wave of infections, Laxminarayan decided he had to try and help. Along with some colleagues he created a charity, Oxygen for India, that locates and transports canisters to the patients with the greatest need. It’s the kind of service that, in normal times, would be provided by governments, not organized by a researcher sitting in his home office. But Laxminarayan argues that, at this point, Indians have little choice but to help themselves. “The system has collapsed,” he says. “If you need something—beds, oxygen—there is nothing that the system can do for you.” By May his colleague was dead.

It’s a situation that hardly flatters Modi, India’s leader since 2014 and arguably its most dominant political figure in generations. The prime minister, who leads the Hindu nationalist Bharatiya Janata Party, came to power pledging to instill managerial competence in the federal government, drawing on his experience as chief minister of Gujarat, a state lauded by businesspeople for its good infrastructure and broad industrial base. Two years ago he was reelected with a thumping majority, and he’s used his mandate to consolidate economic and political power—and, critics say, to undermine India’s democracy and the rights of non-Hindu citizens.

But the scale of the Covid disaster is impossible for even Modi’s most ardent backers to ignore. The press has begun to turn against him, with once-supportive newspapers and TV networks questioning the official death toll, citing their own grim tallies from crematoriums. In an editorial in late April, the Hindu, an influential broadsheet, said the government had “abdicated its responsibility” to the poor by failing to ensure vaccines were available. Even Arnab Goswami, a firebrand talk show host who is to Modi roughly as Sean Hannity is to Donald Trump, has implicitly criticized his performance, thundering in one broadcast that India’s leaders are to blame for oxygen shortages. “They say, ‘we’ve done a lot for the people of India,’ ” he almost shouted. “Rubbish!”

Rather than concede errors, the BJP has attempted to silence its critics, notably by ordering Twitter and Facebook to block posts criticizing the government’s handling of Covid. One of Modi’s closest allies, Uttar Pradesh Chief Minister Yogi Adityanath, has gone even further, threatening to seize the property of citizens and hospitals if they complain publicly about the scarcity of oxygen. Those efforts may be backfiring, delivering setbacks to a political machine that’s rarely stalled since Modi was elected to national office. In early May the BJP lost the election in West Bengal, where the prime minister had campaigned so vigorously until surging virus cases forced him to stop.

The situation on the ground is dire enough that even the most adroit political leader would struggle to change the narrative. Large households are common in India, serving in good times as a source of social resilience, with grandparents looking after their descendants and vice versa. They also provide hospitable venues for viral transmission, allowing Covid to pass rapidly from generation to generation. Whereas earlier waves largely spared the young, Indian doctors have been shocked by the number of children falling ill in the current outbreak, many of them with severe symptoms. There’s no question that many, if not most, of the cases are caused by new variants. In Maharashtra, the state that includes Mumbai, more than half of the sequenced infections contain the little-understood B.1.617 variant, which has prompted some governments to bar Indian travelers.

When the coronavirus first arrived in India last year, Modi imposed one of the world’s strictest and most sweeping lockdowns, taking some pressure off urban health systems but also devastating the economy and spreading the pathogen deep into the countryside, as migrant workers with nowhere else to go returned to their home villages. Although another shutdown would probably buy some time, Modi has resisted the suggestion; his allies argue that India can’t again ask its poorest citizens, many of whom are a couple of days’ wages from going hungry, to stay at home.

With lockdowns most likely off the table, “honestly, vaccination is the only strategy out,” Laxminarayan says. “Without that, we may be looking at a new wave and then a wave after this.”

Since almost the beginning of the pandemic, any plan to end it has depended heavily on India’s vaccine industry. Its most important player is the Serum Institute of India Ltd., a huge manufacturer controlled by the Poonawalla family, a clan of billionaire socialites based in Pune, just inland from Mumbai. A year ago Serum struck a deal with AstraZeneca Plc to manufacture at least a billion doses of its vaccine, which is known in India as Covishield. Adar Poonawalla, Serum’s chief executive officer, planned to split its output between India and other developing countries, assuring politicians and journalists that its production capacity was more than sufficient to serve both markets.

Yet the Covishield rollout was shaky from the start. When Indian regulators approved the product in early January, they also gave a green light to Covaxin, a shot developed by a domestic company, Bharat Biotech International Ltd., that had barely begun final-stage trials. Combined with the well-publicized troubles of the AstraZeneca vaccine, as well as plenty of misinformation on social media, the result was a level of hesitancy that’s rarely been seen in India, which has extensive experience running national inoculation campaigns. It took more than two months for the rollout to reach its planned speed.

When demand did catch up, many of the doses didn’t go to those who needed them most. In a March survey of more than 10,000 people by pollster LocalCircles, 30% said they believed some health-care workers were falsely certifying people as high risk, allowing them to circumvent vague rules on prioritization. “This is India, so nothing is clear,” says one businessman in the technology hub of Bengaluru, who explained how he called around to a handful of clinics in March and soon found one that would give shots to him and his wife—despite neither being in a priority group. “And if things are clear, people find workarounds.”

India’s problem now is squarely one of supply, with Serum making about 70 million doses a month, well short of a targeted 100 million. Partly because U.S. manufacturers were forced by Washington to prioritize domestic orders, it and other Indian companies have complained that they’re short of components such as bioreactor bags and filters. Their efforts to accelerate production have been controversial: Citing the need to fund more capacity, both Serum and Bharat in April raised their prices, prompting an outpouring of rage on social media.

Not surprisingly, Modi is moving to ensure that what Serum does manage to produce stays in India. The company’s exports have been sharply reduced, and planned shipments of 200 million doses to Covax, the global effort to ensure the poorest countries receive vaccine supplies, have been delayed. While the move could be seen as reasonable under the circumstances, it’s giving the virus an opening elsewhere. Nepal and Bangladesh, which were counting on India’s production, saw their deliveries cut, and the former is now experiencing a severe Covid outbreak.

The Indian government is trying to increase vaccine availability by any means possible. Rules requiring domestic clinical trials have been removed, which will allow shots made by Moderna Inc. and Pfizer Inc. to be imported—though both companies’ production is largely spoken for. A three-dose vaccine from another local manufacturer, Cadila Healthcare Ltd., is in final-stage trials and may be approved as soon as next month, and Serum plans to eventually make the shot developed by Novavax Inc., a biotech company based in Maryland. India is also opening its doors to Russia’s Sputnik V. A small initial shipment has arrived, and there are plans to produce more than 700 million doses on the subcontinent annually.

Until vaccine production improves, getting enough needles into arms will be a struggle. Many Western countries hope to reach herd-immunity levels of vaccination by the end of this summer or sooner, but India is on a far slower trajectory. At its current rate of inoculations, according to a Vaccine Tracker, it will be almost three years before 75% of its population is protected.

After the virus appeared in India, Anil Hebbar threw himself into aiding his fellow Mumbaikars, as residents of the country’s financial capital are known. The national lockdown made it difficult for many of the poorest to get food, so Hebbar, who runs a small business selling medical devices, joined a team of volunteers that set up kitchens and went door to door in the city’s slums, handing out groceries. Returning to his apartment at the end of each day, he would try to stay away from his wife and daughter, fearful he’d been infected despite taking every precaution he could think of. But Hebbar didn’t get sick, tempting him to wonder whether a “helper’s high” from his good works might be boosting his immunity.

When a close friend died of Covid, Hebbar felt he had to do more, and in early October he walked into King Edward Memorial Hospital, an 1,800-bed colonial edifice in the heart of Mumbai. There, in a small clinic down a quiet hallway, he became a subject in the Indian trial for the AstraZeneca vaccine. He neglected to mention the plan to his wife; when he finally told her, she refused to speak to him for a day.

In February he tested positive for the coronavirus, and shut himself in his room for two weeks. It wasn’t pleasant, but Hebbar’s symptoms were manageable, particularly for a 56-year-old with diabetes. A couple of months later he found out that he’d been given the real shot rather than a placebo—a stroke of luck that he thinks may have saved his life. If not for those injections, he says, “it could have been very bad for me.”

With the virus having torn through Mumbai, Hebbar is painfully conscious that many of his fellow citizens don’t share his good fortune. The city’s usually bustling streets are quiet, apart from the wail of ambulance sirens. Countless numbers of friends and relatives have been infected; in Hebbar’s nine-tower residential complex, five of the buildings had been sealed by local authorities after recent outbreaks. “I’m scared to open Facebook,” Hebbar says. “You only see who has died, and you know so many of them.”