In India’s COVID-19 catastrophe, figures are only part of the story

By Payal Dhar

India’s COVID-19 curve resembles a vertical line right now. An already fragile health infrastructure is on its knees, the government has shown itself to be incapable. There are no hospital beds to be had, no medicines, no oxygen, no emergency care; even the dead have to endure 20-hour queues for last rites. A nine-day streak of 300,000-plus new cases daily has ended with fresh infections crossing the 400,000 mark on May 1. More than 3,000 COVID-related deaths have been recorded daily for three consecutive days. Still, the worst, experts say, is yet to come.

If one compares India’s cumulative figures with the U.S.’s, however, the numbers don’t seem to make sense. India’s 18.8 million confirmed cases, with 208,330 deaths, don’t seem anywhere near U.S. figures of 31.9 million and 568,836 respectively. India appears to record 1,360 cases and 15 deaths per 100,000 people, versus 9,684 cases and 172 deaths per 100,000 people in the U.S. Even accounting for the fact that India’s population (1.4 billion) is more than four times that of the U.S. (330 million), the scale of the devastation seen on the ground—patients three to a bed or being treated on the streets, people dying outside hospitals waiting for treatment, entire families being wiped out, and mass cremations taking place on pavements and car parks—appears disproportionate.

The reasons are complicated and intersecting. For one, the official figures are highly likely to be vastly underestimated in India. Moreover, the country’s health infrastructure has always been fragile. There are only 5.3 beds per 10,000 population (versus 28.7 for the U.S.), and given the sheer numbers of COVID-19 infections, it’s simply a case of just-not-enough. Other reasons for the low numbers in India could, quite simply, be a lack of testing—only 1.74 daily tests per 1,000 people—as well as a purposeful obfuscation of actual figures.

Experts say that COVID-19 deaths have been undercounted across the world for various reasons; testing methodologies and the recording of confirmed cases has not been uniform. “Every country reports those figures a little differently and, inevitably, misses undiagnosed infections and deaths,” Reuters’ COVID-19 Global Tracker states.

It’s like looking at an iceberg, says one of India’s top epidemiologists, Dr. Jayaprakash Muliyil, chairperson of the Scientific Advisory Committee of the National Institute of Epidemiology, in a phone conversation. “The number of cases the system picks up is a fraction [of the actual number of infections],” he says. “A large number of cases are subclinical [not severe enough to present definite or readily observable symptoms].” This fraction depends on several factors—it is lower in smaller states with better infrastructure, like Pudducherry, and higher in others with greater population density, like Bihar.

A recent study found a “severe under-ascertainment of COVID-19 cases” across U.S. states and countries worldwide. “In 25 out of the 50 countries, actual cumulative cases were estimated to be 5–20 times greater than the confirmed cases,” report authors Jungsik Noh and Gaudenz Danuser, adding that, “The estimation of the actual fraction of currently infected people is crucial for any definition of public health policies, which up to this point may have been misguided by the reliance on confirmed cases.”

Serological surveys (using antibody tests) indicate that the actual number of infected people could be 30 times higher in India than what official figures show. COVID-related deaths could be anything between 2 to 5 times and 10 to 15 times than what is being reported.

Modeling methods may be a headache, but pandemic curves always come down, and this one will too, says Dr. Muliyil. He is not a fan of lockdowns for a country like India—having said back in September that it had flattened the wrong curve, that of the economy. With newer mutations of the virus appearing to be more easily transmissible, he says that an infection rate of 70 to 75 percent might be required for herd immunity. Meanwhile, “natural protection to the virus is excellent.” He prescribes strategic vaccination—focusing on the 45-plus age group rather than younger people, and those who haven’t been infected— and “bring back the urge to mask up and avoid crowds.”

Payal Dhar is a freelance journalist from India who writes on science, technology and society.

Editor’s note: If you would like to contribute to help the situation in India, here are three recommendations from Payal:

The COVID-19 Data Dispatch was able to compensate Payal for this piece thanks to the support of the COVID-19 Data Dispatch’s members. We hope to be able to feature more guest writers in the future—if you’d like to support this work, please consider a contribution.

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