India’s COVID crisis

Political scientist Tariq Thachil and economist and public health expert Harsha Thirumurthy take a look at India’s public health and politics.

Rows of houses with corrugated metal roofs are interspersed with trees. A mountain range is in the background
“Everyone’s biggest worry was that India... was extremely vulnerable, given that its population of 1.4 billion people live in very densely populated areas,” says Harsha Thirumurthy. Pictured: Jaipur, India. (Image: Adam Auerbach) 

After the first wave of the pandemic subsided in India, the country began to relax its precautionary measures, including a stringent lockdown that required millions of migrants to journey back to their home districts with less than four hours’ notice. The country’s COVID case rate peaked at more than 90,000 new diagnoses per day in September, then seemed to slow. By the winter of 2021, key figures within India’s incumbent political party, the Bharatiya Janata Party (BJP), claimed that India had now defeated COVID under the visionary leadership of Prime Minister Narendra Modi, says Tariq Thachil, associate professor of political science and director of the Center for the Advanced Study of India (CASI). Last January at the World Economic Forum in Davos, Switzerland, Modi himself claimed India had saved humanity by containing the coronavirus effectively. 

By the end of March 2021, however, the line graph of India’s confirmed COVID cases took a sharp skyward turn. The country is currently averaging more than 350,000 new cases per day in what “has been quite a perplexing issue for many folks who have been studying the pandemic,” says Harsha Thirumurthy, associate professor of medical ethics and health policy at the Perelman School of Medicine. “We don’t know which hypotheses best explain this really dramatic second wave,” but it is most likely attributable to a combination of factors, he says.

“The first problem was that there was kind of this early triumphalism by Modi and the BJP that perhaps misread the initial policy actions and how effective they were,” Thachil says. As the first wave began to subside, India began to relax its national and local lockdowns, and the economy began to open up without a corresponding focus on crisis preparation, he says. 

“It led to this long period in between the first and second wave that ideally would have gone towards kind of ramping up the country’s inadequate public health infrastructure to deal with exactly this kind of crisis, and that didn’t happen,” says Thachil. “Perhaps even more disturbingly, in terms of not just the public health consequences but the symbolic consequences of these actions, the ruling government actually supported several forms of mass gatherings.” 

Notably, the Kumbh Mela, a Hindu festival with several million attendees, was moved up a year due to auspicious astrological signs. This was a sign of complacency, Thachil says. “Such a big public gathering at a time when we’re still globally not out of the woods with COVID-19. Far from it.”

In addition, in-person mass rallies were held in advance of the 2021 elections, which occurred in phases between March 27 and April 29. These rallies spanned the political spectrum, Thachil says, but to the degree Modi “is wishing to position himself and claim the lion’s share of credit as somebody who was responsible for India’s COVID successes, I think equally then the prime minister should assume primary responsibility for allowing his party to hold those rallies, personally participating in those rallies, and even favorably commenting on the number of participants at those rallies,” he says. “And this is despite warnings from scientists in his own government of new and potentially more contagious variants of the virus within India.” 

India’s election commission “also should come in for some for some scrutiny and blame,” says Thachil, for scheduling elections over eight phases, “which is extremely long, even by Indian standards.” He notes that the commission was criticized in the Indian press for suspicion of bias towards the BJP. “Its performance is underwhelming and disappointing given everything that was coming out about the dangers of holding these large rallies over such a long period of time,” he says, “showing real weakness for an institution that often is lauded for its role in ensuring free and fair elections in India.”

While the political rallies and religious events “undoubtedly contributed to the second wave,” there are additional factors to consider, says Thirumurthy. In addition to complacency towards public health measures like masking and social distancing, some data suggests that India’s first wave affected more people than what was reported via COVID testing, he says. 

Data from cities like Delhi and Mumbai show that 50% or more of their population tested positive for antibodies, indicating that those individuals were likely infected during the pandemic’s first wave. This hypothesis is consistent with the fact that those living in informal settlements are now reporting fewer new cases, Thirumurthy says. “The first time around, we know for a fact that the number of cases that were officially detected was a vast underestimation.”

Another contributing factor may be a new variant, B.1617, that’s more transmissible, Thirumurthy says. Given this concern, “we have to wonder whether many of the individuals who had antibodies are being reinfected.”

In order to mitigate the spread, India needs to see two widespread initiatives, Thirumurthy says. The first is a behavioral response, including more mask compliance and a greater degree of physical distancing, accomplished either through additional lockdowns or individual precautions. “We absolutely need to have that, and we’re seeing some of that in a few cities and states.

“The second would be to greatly accelerate pace of vaccinations in India. As of now, we’ve seen something like 3% of the Indian population being fully vaccinated,” Thirumurthy says. More than 170 million COVID vaccine doses have been administered in India, mostly the two-shot doses of Covishield and Covaxin. As of yet, most have received just the first dose, but “even the first dose can be protective,” he says. 

“I think there’s a moral imperative to send excess supplies to countries like India where vaccine access is much lower,” says Thirumurthy. “And it goes without saying that at the end of the day, it’s going to be global vaccination coverage that’s going to make the difference in terms of slowing the spread of COVID.”

The Biden administration recently announced its support of the World Trade Organization’s proposal to temporarily waive intellectual property protection for COVID-19 vaccines. Relaxing these regulations is important but does not entirely solve the problem, says Thirumurthy. 

“If there isn’t, say, access to the raw materials that one needs to produce those vaccines, then even relaxed intellectual property regulation is going to be somewhat toothless in terms of its effect on vaccination coverage,” he says. It is necessary to look carefully the impediments to exporting raw materials, Thirumurthy says. “Is it due to export controls or trade policies that are keeping raw materials from being available to manufacture vaccines? I think it’s hard to boil it down simply to intellectual property, although that is extremely important.”

It’s also imperative to have a big push to enable essential health services that would boost India’s capacity to treat COVID-19 patients, says Thirumurthy. “I think that’s going to require a big effort, by the Indian government but also by the international community, with particularly high-income countries providing the kinds of resources and technical support that are needed to establish more hospitals” and provide a higher quality of care.  

This devastating second wave of the pandemic in India foreshadows a compounding effect of COVID on poverty “in a country that already has the highest percentage of people living in poverty in the world,” Thirumurthy says. Today’s crisis will have a long-term impact on public health, education, and other human capital outcomes, he says. “We’re only scratching the surface of the impact on living standards.”

Thirumurthy grew up in India, and “it is certainly very sobering and harrowing to read about what’s happening there and to see firsthand, in a very personal way, the disparities” in access to essential health services like COVID vaccines, he says. “We have to take a global perspective when it comes to vaccine delivery and vaccination coverage. The longer we have populations that are not vaccinated and the longer this second wave continues, I think the more potential there is for mutations to occur.”

The COVID-19 crisis in India is not a problem that’s limited to one country, Thirumurthy says. A virulent second wave is also happening—so far to a lesser extent—in South America, particularly in Uruguay and Brazil. 

“The safety of people around the world hinges on our ability to control the spread of these new variants,” Thirumurthy says, noting case surges in neighboring countries, including Nepal. “If we have very low vaccination coverage in those places, these countries are going to be just incredibly poorly equipped to handle a surge like what we’re seeing in India,” he says. “We need to be planning ahead for that as much as possible.”

As much as it’s reassuring to see a successful rollout of vaccines so far in the United States, there’s concern for the future, he says, “because these newer variants could very easily arrive here. India’s current crisis also underscores the importance of not becoming complacent, even as the number of new cases decline. What we’ve seen in India is just a classic example of how rapidly you can see a surge in cases if there is a relaxation of basic prevention measures.”

As for Modi, he and the BJP made historic gains in West Bengal—the site of some of the largest political rallies this spring—but ultimately lost that state’s election to the incumbent party. While the prime minister is receiving criticism of his pandemic response, what “we’ve seen under Mr. Modi's leadership is that irrespective of how difficult the situation may be, he’s shown a remarkable ability to come out of it, not only unscathed but as popular sometimes even more popular than before,” says Thachil. “I would be cautious about assuming that he would take a large hit from this crisis. That said, this second wave has undoubtedly presented the most challenging moment he has faced in his seven years as prime minister.”

While there is no “magic bullet that will solve all problems,” an effective response to India’s COVID crisis would include a “kind of global solution and global response that treats all life equally,” Thachil says.

“Everyone’s biggest worry was that India, more than any other part of the world, was extremely vulnerable, given that its population of 1.4 billion people live in very densely populated areas,” says Thirumurthy. “Our worst fears are coming to pass in that sense.” 

Tariq Thachil is associate professor in the Political Science Department, director of the Center for the Advanced Study of India, and the Madan Lal Sobti Associate Professor of the Study of Contemporary India in the School of Arts & Sciences at the University of Pennsylvania.

Harsha Thirumurthy is the associate director of the Center for Health Incentives and Behavorial Economics and associate professor of medical ethics and health policy in the Perelman School of Medicine and senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.