How India’s Covid-19 Tragedy Was Almost America’s Reality

This article first appeared on Forbes.com

The scenes and stories coming out of India grow more heart wrenching each day.

At overflowing hospitals, Covid-19 victims are dying in front of locked gates. Doctors and nurses are making hourly decisions about which humans deserve a chance to live off an agonizingly short supply of drugs and oxygen. Crematoriums are running 24 hours a day, unable to keep pace with demand. Bodies are being burned each night in parking lots. By the coming dawn, the asphalt is caked in ash and bone.

None of these horrific images seemed possible even two months ago. And it’s terrifying to think how close the United States came to sharing a similar fate.

India surprised scientists—at first

Rewind to spring of 2020. Researchers already knew that the Sars-CoV-2 virus spread rapidly when large groups of people gathered in close proximity. For this reason, epidemiologists worried that India, a country of 1.4 billion people, would get the worst of it. They feared the country’s congested and impoverished cities would act as cauldrons for viral transmission.

They were wrong. At least, at first.

For most of 2020, India’s municipalities maintained a relatively low incidence of Covid-19 infection and death. Scientists couldn’t be sure why, exactly. Theories revolved around the nation’s relatively low obesity rate—especially compared to the United States where obesity and diabetes proved to be key drivers of Covid-19 hospitalizations. There was also speculation that India’s tight living quarters might have produced millions of subclinical infections, creating a mild, natural immunity.

Then things took a turn, and then another 

Fast forward a few frames to fall 2020. Following a sudden Covid-19 spike in which India saw its daily case count shoot up to 90,000-plus, much of the nation shut down. The decision proved economically brutal but medically shrewd. Many unemployed workers moved out of cities and into the surrounding farmlands. As people spread out, India’s case count stabilized.

By the new year, India’s daily infection count was under 20,000. The United States, by contrast, was getting blasted by the virus. Owing to holiday gatherings and “pandemic fatigue,” U.S. daily infections soon topped 250,000. Taking population into account, the rate of infection in the United States was 40 times higher than in India.

This teeter-tottering of nations in crisis might have continued indefinitely if not for one pandemic-altering event.

America’s big bet

While nations like New Zealand, South Korea and Singapore were instituting rigorous shutdowns, implementing invasive contact-tracing strategies, and imposing mandatory quarantines, the United States took an entirely different tack. 

As those nations doubled down on slowing the spread, American leaders pushed all their chips to the middle of the table, betting everything on a vaccine.

By summer 2020, funds earmarked for the CDC and protective medical gear had been diverted toward an all-out-vaccine-blitz called Operation Warp Speed (OWS). By August, the U.S. federal government had pre-ordered and paid roughly $18 billion for more than 800 billion doses.

If the operation proved successful—both in terms of the vaccine’s development and the nation’s willingness to take it—Americans would have a leg up on achieving “herd immunity.” Immunization was our nation’s chosen strategy to end the pandemic.

America’s outsized risk

Looking in the rearview mirror, it’s easy to forget that this strategy was incredibly chancy.

First, there was no reasonable cause to think scientists could develop an effective vaccine at “warp speed.” The fastest development time in history for a successful vaccine had been four years (mumps). All others took five years, or much longer, or never came to fruition at all.

Today, there is still no HIV vaccine, no universal flu vaccine, nor any vaccines with long-lasting protection against malaria or tuberculosis. There are still no cures for two other notable types of coronavirus: severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). This was not for lack of trying.

But even if researchers could fast-track a Covid-19 vaccine, what were the odds it would be highly effective? Guidance from the FDA in June 2020 read: “…the primary efficacy endpoint point estimate for a placebo-controlled efficacy trial should be at least 50%.” In other words, the nation’s leading drug regulator was ready to approve a vaccine that was only 50% effective against the coronavirus. Even the nation’s leading epidemiologist, Dr. Anthony Fauci, went on record to say that he would settle for a 70% to 75% effective vaccine, hoping one would be “widely available” by mid-2021.

Major drug companies like Pfizer, Moderna and others vying to create a Covid-19 cure were relying on a method that had not produced a safe or effective mRNA vaccine against any viral infection in more than two decades of research. 

Even as late as October, no drug maker had yet completed large-scale, phase III clinical trials. If Vegas had given 10:1 odds that multiple drug makers would go on to manufacture and distribute tens of millions of doses of an extremely effective, remarkably safe vaccine by year’s end, I would have cautioned anyone against taking that bet.

Smart bet or dumb luck?

American researchers defied the odds in grand fashion. As healthcare expert Eric Topol stated in a recent Tweet: “This will go down in history as one of science and medical research’s greatest achievements. Perhaps the most impressive.”

But imagine what might have been if the vaccine had taken two years to develop—half the previous record. Most scientists would likely have labeled it a remarkable achievement. But our nation would not be on a path to “getting back to more normal living” as President Biden assured his fellow Americans last week.

Without a vaccine, it’s likely that the highly contagious triple-mutant Covid variant, or any of the 10 other variants known to be more transmissible than the original, would be spreading in the United States as easily as in India.

And if that had been the case, we’d be watching infections rise and hospital beds grow scarce. Death from Covid-19 would become the rule more than the exception. American metropolises like New York, Los Angeles and Boston would look eerily similar to New Delhi and Calcutta now—with bodies piling up in morgues and, when those overflowed, warehouses.

If you doubt this would have been likely, or even possible, ask yourself whether the coronavirus is capable of discriminating by nationality. Ask yourself whether an American is intrinsically more immune than a person in India. Finally, ask whether our nation’s leaders and populace had found any consistent success slowing the spread of virus prior to the vaccine rollout.

The answer to all three questions is decidedly “no.”

In retrospect, betting on a vaccine proved to be a smart wager—or a lucky gamble, depending on one’s perspective. Half of all eligible Americans have received at least one dose, which is why our nation is experiencing its lowest death rate since the pandemic began. Meanwhile, India is documenting more than 400,000 cases per day. Tragically, given the severely restricted testing capacity, the true number of infections in India is doubtless much higher.

A dose of humility

Had the spike protein on this specific coronavirus not been such a perfect target for a mRNA vaccine, or had the process for developing and manufacturing Covid-19 vaccines taken two years instead of one, or had a highly transmissible variant developed earlier in the pandemic, the U.S. death toll would have easily eclipsed 1 million by now (rather than half that number).

Our nation benefited from exceptional science, but it also benefited from luck.

We can celebrate our success or consider ourselves fortunate. Either way, we should urge everyone who remains unvaccinated to get their first shot.

Nearly 100% of Covid-19 deaths in the United States today are among unvaccinated people. The risk of infection and death should be reasons enough for hesitant Americans to sign up for vaccination.

Those who still refuse should be forced to watch video footage from India. See the bodies burning in open fields beneath teepees of dried lumber. See critically ill patients choke to death without access to oxygen. And after seeing these horrific images, perhaps every Americans will realize the truth: that the Covid-19 vaccine is what separates India’s ongoing tragedy from our present reality. And hopefully they’ll decide to get vaccinated.