India sees 100,000 COVID-19 deaths: What happened and what now?

India has crossed the grim milestone of 100,000 coronavirus deaths, the third-highest in the world behind only the United States and Brazil.

Despite the South Asian nation’s attempts to control the spread of the COVID-19 disease, which included one of the world’s strictest lockdowns, infections have surged at an alarming pace.

To date, India has more than 6.6 million cases, second only to the US. On Monday, it registered a single-day spike of 74,442 new cases, while 903 virus deaths in the past 24 hours took the total fatalities up to 102,685.

However, the country’s recovery rate stands at 84 percent, the highest in the world, with more than 5.5 million people recovered from coronavirus so far, according to the health ministry.

As per the recent serological surveys done in the capital New Delhi and the financial hub of Mumbai, the ratio of infections to recorded cases are 20:1. Thus, India has more than 120 million COVID-19 infections, instead of the recorded 6 million.

It is also evident the infection-fatality rate (IFR) is as low as one per thousand. COVID-19 deaths add up to less than 1 percent of annual deaths from all causes in India. There have been 38 coronavirus deaths per million population, compared with more than 500 in the US.

Mortality will spurt because routine health services including antenatal care and immunisation have been disrupted due to the pandemic. The COVID-19 hotspots have dispersed from prosperous metropolises such as New Delhi, Mumbai, Chennai, Bangalore and Hyderabad, which have better health systems, to the hinterlands where health services are very weak.

India’s prolonged lockdown devastated livelihoods, causing acute food insecurity, translating into higher mortality and malnutrition, especially among children. The monetary relief from PM Cares fund – set up by federal government to fight coronavirus – and announcements by the ministry of labour and employment to safeguard jobs, wages and support the self-employed remain to be implemented.

India opted for complete lockdown when the cases were low to save “lives”, but started unlocking when the numbers surged in millions for “livelihoods”. The hotspots were to be contained and not the whole country, which would have allowed people to travel home without perils. Students have been left to deal with the uncertainty of academic activities. Domestic violence has increased, causing anxiety and stress-related mental health problems.

The government denied any “community transmission” of COVID-19 for a long time. The much-talked-about front-line workers remained exposed to the infection as well as the wrath of the state if they became critical of the government’s crisis response.

The recent accolades regarding the increase in the recovery make little sense as the COVID-19 has a recovery rate of more than 99 percent in India. The state seems to be more indulgent in image-building than crisis management.

Lockdown-induced restrictions on movement have created fear, leading to anxiety and panic. It is important to restore the trust that care will be available through restoration of routine services of all kinds. Students in institutions of higher education be brought back to the physical form of learning with due measures in common spaces like hostels and classrooms, without panic.

Given the low fatality, most confirmed cases are mild and can be treated at home. So the stigmatisation of positive case needs to be minimised through right communication. This will release the already burdened health services to deal with the severe and fatal cases.

Prabhat Jha, epidemiologist, University of Toronto, Canada

India is not flattening the COVID mortality curve. Testing is affected by expanding test sites. However, since 80 percent of deaths in India occur in rural areas and mostly without medical attention, their causes of death are not known.

Mumbai has most reasonable mortality data, the city is capturing most deaths and having physicians certify them. If you look at Maharashtra state’s (where Mumbai is located) mortality curve, it is still not flattening. On the other hand, the growth rate of deaths in India is far slower than in high-income countries for reasons we do not know. The younger age distribution might be one factor.

The lockdown in India was also accompanied by a mass exodus, but the government should have banned landlords from kicking out tenants in cities. These (mostly young men) went back to their villages, taking infection with them.

In villages under lockdown, infection would be mostly confined to homes and not spread as much as if there were no lockdown. Thus, there might be notable but undocumented increase in deaths within homes in rural areas.