India passes 1 million coronavirus cases despite one of world’s strictest lockdowns. What went wrong?

Analysis: Country was praised for its early and strict lockdown – but it now has few options left to contain its growing outbreak, explains Adam Withnall in Delhi

A health worker sanitises the gloves of another member of staff inside a booth in New Delhi (AP)

In late March, when India first entered the world’s largest and strictest national coronavirus lockdown, it was widely seen as being a bit of an overreaction. Over the weeks that followed, as the virus spread with devastating impact across Europe and the Americas, opinions about the Indian government’s approach were quickly revised – perhaps it was a masterstroke from the Modi administration after all?

On Friday, however, India’s number of coronavirus cases tipped over the million mark, placing it as the third-worst affected country in the world. The daily increase of nearly 35,000 cases was also a new record for the country, suggesting the epidemic here is still far from reaching a peak.

Some experts suggest that the timing and scale of India’s lockdown may actually prove to have exacerbated its virus crisis, with the economic and humanitarian cost being so devastating that the country is now unwilling to reintroduce stay-at-home measures in places where they are needed now more than ever.

Dr Ramanan Laxminarayan, director of the Washington-based Centre for Disease Dynamics, Economics and Policy, says one of the two big mistakes that India made in its Covid-19 response was to lock down hard on 24 March without “thinking it through a lot better”.

India’s national lockdown came with just four hours notice, and caused millions of migrant labourers to flee major cities for their home states. While this led to dangerous and sometimes deadly journeys for the workers themselves, it also contributed to the disease’s spread across the country, and the poorer agrarian states of Bihar and Uttar Pradesh are likely to be the next major hotspots in the country.

The lockdown, Dr Laxminarayan says, was “very much a knee-jerk reaction”. “Decisive actions were taken, there was good intent and a willingness to act promptly, but there was also a lack of planning and execution and a lack of science [to the approach].”

Dr Sumit Ray, head of critical care at the Holy Family Hospital in Delhi, went on national TV last month to call for a second lockdown in the capital as new cases hit 4,000 a day. Delhi’s leaders, after meeting with the central government, firmly ruled out any such measures and continued to open up the city.

He says the fallout of the early national lockdown, and its impact on the economy, has made it much harder for politicians to call for localised lockdowns now.

“We should have waited and watched a little longer,” he says. “The timing of the lockdown does matter – now we are in a situation where everyone is scared of lockdowns, where we can’t go into [another one] because we did the lockdown earlier.”

An earlier roll-out of testing might have rendered a complete national lockdown unnecessary. While India is now second only to the US in the number of tests it has carried out, it only recently started ramping up the process once it could no longer deny the severity of the situation on the ground.

“Testing was really poor initially,” says Dr Laxminarayan. “[The government] tried to control the narrative. They thought they could control it by hiding deaths, by not testing enough. But it turns out states that have tested a lot have actually done better at controlling the disease, while others like Delhi didn’t know where they were being hit from.

“Testing was always part of the messaging from public health experts to the government. It just didn’t start getting taken seriously until May or even June, really, and we lost valuable time.”

While there are certainly lessons to be learned from India’s outbreak, it is also true that it could have been even worse, given the country’s chronically underfunded health system, crowded towns and cities, and huge population.

The country’s cases per million are around 658, about 16 times lower than the US. Dr Giridhar R Babu, a professor of epidemiology at the Indian Institute of Public Health who has been advising the government on its Covid-19 response, argues that “in India, absolute numbers do not mean much”.

Dr Babu also notes that India is “doing well” in term of deaths, with its 25,602 putting it eighth in the world – again, in spite of its various chronic handicaps.

And patient outcomes have been improving, with the country recording almost two thirds of its one million cases as fully recovered. “We should measure the success of each country’s Covid-19 response in its ability to save lives,” Dr Babu says.

Even those who have criticised the official response here admit that on the point of public messaging, the government has performed well.

“The political-level communication about the seriousness of Covid has been exceptional throughout the country,” says Dr Laxminarayan. “I don’t think India can be compared with Mexico or Brazil, or even the US or UK for that matter, where the senior leadership didn’t appear to take the disease seriously.”

The biggest hope from experts here is that India will collectively learn the key lesson of this pandemic – that a strong public healthcare system cannot be built up overnight, however much time you buy through lockdowns.

“India could forget that it ever had this pandemic and go back to the same low levels of spending on health,” says Dr Laxminarayan. “Or it is possible that current and future governments will take this seriously and realise that health investments take decades, and that being ready for the next pandemic means starting [to spend] tomorrow.”