Why did India do well with Covid?

Why did India do well with Covid? This is a question that has been asked many a time as India so far has avoided a second wave and the economy seems to have bounced back to normal faster than what most people expected. This is remarkable given that for a few weeks in August and September it felt like India will be the country with largest cumulative Covid infections and Covid related deaths.(1) In total cases per mn, India is 119th in the world (7,862 infections per mn) and in deaths per mn, India is 108th (112 per mn). (2) Even within this there are 2 or 3 states that have been badly impacted and some of the larger states have been relatively much better off. If USA, the worst impacted country in the world so far, had the same proportion of cases then total infections would have numbered 2.59mn vs the 28.6mn now; number of deaths would have been just under 37,000 and not nearly 0.5 mn.

This is a remarkable achievement for a country with per capita income of just over US$2,300, where over 50% of the population in large metropolises are believed to be residing in slums, the medical infrastructure is poor and one of the most challenged among large nations, and social distancing and sanitation are a luxury even in normal times for a large percentage of the population. However, it is also a fact that just not India, but other countries in South Asia and Africa have done much better than what was expected and many of the developed nations in the western world have not done well.

There are no correct answers to the question yet, but a lot of “theories” are being put forward since the beginning of the pandemic, which I will try and summarize in this blog. Over the next few years we may have some credible answers but for now let me summarize some of the “theories” and also what has happened on the ground, although there may or may not be any cause and effect relationship:

Demographics: A young population helped India. More than 50% of the population is below 25 years of age (have lower risk and higher recovery) and less than 5% above 65 (highest risk of mortality).

Pre-existing immunity: India is a polluted country and people live in unhygienic conditions. As a result Indians are exposed to many germs, microbes, bacteria and viruses and there is some form of natural in-built immunity.

Geography: A warm climate provides better protection against the Covid virus.

Vaccination: Since the vaccination program for children is quite robust and children get vaccinated for BCG, it may have provided protection against the new virus us well.

Herd immunity: While not explicitly trying for herd immunity, Indian may have achieved it or be close to it, at least in the large metro cities where seroprevalence studies are finding that 50%+ population in slums have anti-bodies(3) and over 20% of the population has anti-bodies. Most people had mild symptoms and often treated it like just another flu or fever or infection and did not need any hospitalization or specialized medical care or attention.

Presence of human protein – neutrophil elastase - in lower quantities among Asians than in USA and Europe may have helped in the slower spread of Covid-19 infection in Asia, according to one research.(4)

Unfortunately what is less discussed and given less credit for are government interventions, at every level, and the work of healthcare professionals and frontline workers, which includes the police and municipal employees. There was a nationwide effort and coordination and cooperation between different levels of government and its different arms. While the focus of much of the media was devoted to the crisis of migrant workers, poor conditions in public hospitals and the human tragedy unfolding in individual homes, the larger picture was lost or was ignored. Below I highlight the efforts of the government and frontline workers and some of the other reasons for India’s seeming success:

Restrictions on international travel: The government sounded the alarm bell on the pandemic immediately after President Trump’s visit, when there were very few cases, although Modi’s critics feel he should have done the same earlier. One of the first major decisions was to restrict international travel to and from the country and ban on international flights from Europe and USA. The External Affairs minister is on record saying that the country faced a lot of pressure from other countries not to do so, but it remained steadfast in its decisions. With that came the testing, isolation and contact tracing for international passengers.

There are stories of how the tests were circumvented or contact tracing was less than perfect, but it increased the level of awareness and seriousness of the pandemic. I know of several people who were very impressed with the follow up by municipal workers that was taking place once they had reached their homes. 

Severe lockdown: As is now well-known, a very severe lockdown was announced in late March, which continued through till May-end, when slowly restrictions started being eased. This was a national level lockdown and brought the economy to a complete standstill. It also forced people to stay indoors; it also forced people to start using masks, and sanitizers. The prime minister exhorting on national television the need to wear masks, the need to follow sanitization and social distancing had its impact.

The lockdown gave the government at every level time to at least partly get its act together. Protocols for contact tracing evolved quickly, testing facilities and protocols were put in place, contact tracing started in the right earnest and processes and systems evolved for isolation of infected persons, disinfection of buildings and apartment blocks if someone was infected was done in the right earnest. The lockdown bought time to set up large isolation facilities, commission beds from private hospitals, commission hotels as isolation centres and start the production of PPE kits, masks and sanitizers. It is a good case study on cooperation between the private and public sectors.

Wearing masks in public was made mandatory, all large get-togethers were prohibited and proactive early interventions started. These restrictions remained in place mostly till December. When caught without masks, people were being fined and then given free masks. Sometimes it went to absurd proportions and you could be fined if you were with your family in your car but were not wearing masks, as I know happened in Delhi! Public places like restaurants and hotels started opening up only from November and December. The government mandates, at central and local levels, did help to drive behavior change.

 Many things did go wrong when the lockdown was announced, foremost among them was the migrant workers crisis. It seemed that the government believed that lockdown was enough to drive out the pandemic and life will be back to normal in two weeks. When that didn’t happen, the government appeared clueless to outside observers and migrant workers panicked and started moving to their villages by any means available.

 Smart use of resources: In a large country with 1.3bn people and 65% of who reside in rural areas, the one thing that connects almost everyone is the mobile phone. The government used the caller tune of mobile phones to convey the seriousness of the pandemic and the need for use of mask and sanitizers. These pre-recorded messages in various Indian languages, often using the voice of celebrities, were the most effective tool in helping to reach the message far and wide. There could not have been an easier or cheaper way for mass communication. Even mass efforts like honoring healthcare workers by lighting candles or ringing bells had its impact as people came together to do it. The nation seemed united to fight the pandemic, even if these activities were only symbolic.

Treatment protocols: Very early on hospitals and doctors started using medicines and developing treatment protocols, including use of traditional immunity building concoctions like kadha(5). For example, all frontline workers of Mumbai Municipal Corporation were given dosages of hydroxychloroquine (HCQ) and zinc (Zn) tablets. Very early on I remember that I bought HCQ tablets and kept them at home just in case, following the recommendation of a friend in the pharmaceutical industry. While the HCQ has not been consumed, the family has had one or two rounds of Zn and Vitamin D tablets, kadha and also Camphora 1M, a homeopathic medicine(6). Ivermectin was another drug that has been widely used. In medical centres and hospital anyone testing positive and not requiring hospitalization is usually given a packet of medicines, comprising of some or all of the above.

It is not known what worked or if any of it worked at all, but the results are what they are.(7) When my son was leaving for his college in USA in January, his dermatologist – yes, dermatologist – gave him a list of medicines to carry with him and instructions of what to have and when based on symptoms since it will be difficult to buy those medicines in USA and no doctor was going to prescribe them. She also mentioned that she has been asked for these medicines by her doctor friends in USA. This is clearly not gold standard of medical treatment; this in another day or another country may well be dubbed as irresponsible behavior, but then these are not normal times.

Society and Social behavior: LFPR for women in India is very low, lower than even neighboring Bangladesh and slightly higher than Pakistan. With a majority of half the population being indoors even in normal times and having limited social life or public movement, especially in rural areas, there was natural social distancing. The elderly population, small in overall proportion in the population, mostly stay with their children or stay on their own. Old age homes and communities are non-existent and these are the places where maximum deaths have occurred in the west. Families and housing societies had imposed special restrictions on the movement of children and the elderly. This may also have helped.

Whatever may be the reason, India cannot be complacent. While we seem to have navigated the festival season and New Year festivities well, we do not know what is lurking in the corner. Mumbai suburban trains, the lifeline for workers in Mumbai, opened its services for the general public from 01st February, and there is an increase in infections in Mumbai in the last one week. Let’s hope this is not the beginning of a second wave. Meanwhile vaccination roll out has started and hopefully it will gather pace. Till some 300mn people are vaccinated in the first three phases, the masks, sanitizers and social distancing need to remain in place. It’s not yet time to party like the pre-Covid times.

Note: Please leave your comments, feedback or anything else that you have read on this subject.

(1) In May, Washington Post carried an article how the issue was one of survival in Dharavi, Mumbai’s largest slum: https://www.washingtonpost.com/world/asia_pacific/dharavi-coronavirus-india-slums-mumbai/2020/05/11/beb2a4fe-8e1b-11ea-9322-a29e75effc93_story.html. By September, World Bank and others were praising the efforts and results in Dharavi: https://www.livemint.com/news/india/world-bank-praises-efforts-to-arrest-covid-19-spread-in-mumbai-s-dharavi-11602065057782.html.

(2) Source: https://www.worldometers.info/coronavirus/.

(3) https://www.wsj.com/articles/over-half-of-residents-in-mumbais-slums-were-exposed-to-coronavirus-survey-finds-11596143800.

(4) https://timesofindia.indiatimes.com/india/protein-behind-coronas-slow-asia-spread-study/articleshow/80757537.cms.

(5) Indian media was full of articles like these: https://indianexpress.com/article/lifestyle/health/kadha-herbal-drink-pandemic-immunity-how-much-to-have-6703868/ and https://www.dhirubhai.net/redir/general-malware-page?url=https%3A%2F%2Ffood%2endtv%2ecom%2Frecipe-kadha-chai-954386.

(6) Rajiv Bajaj, a severe critic of the lockdown policy, took homeopathic medicine and gave the same to all Bajaj Auto employees: https://www.timesnownews.com/auto/features/article/rajiv-bajaj-and-bajaj-employees-relying-on-homeopathy-to-boost-immunity-against-coronavirus/591243.

(7) Two recent articles discussing India’s success so far: https://trialsitenews.com/an-unlikely-nation-is-kicking-this-pandemic-guess-which-then-why/ and https://www.npr.org/sections/goatsandsoda/2021/02/01/962821038/the-mystery-of-indias-plummeting-covid-19-cases.