Can India Avert a Health Apocalypse?

The world’s largest democracy is particularly vulnerable to infectious diseases—but history shows it can be surprisingly resilient.

A health worker checks the body temperature of a woman amid concerns over the spread of the coronavirus at Kapaleeshwar temple.
A health worker checks the body temperature of a woman amid concerns over the spread of the coronavirus at Kapaleeshwar temple in Chennai, India, on March 17. Arun Sankar/AFP/Getty Images

As India braces for the rapid spread of the coronavirus, its health care system offers limited comfort. The country spends only 3.66 percent of its GDP on public health, while some of its smaller neighbors such as Nepal (6.29 percent) spend a much higher proportion. Advanced economies are even further ahead: The United States, for example, spends about 17 percent of its GDP on health care; Germany and the United Kingdom spend 11.14 percent and 9.76 percent, respectively.

Other indicators are not heartening either. India has just 0.5 hospital beds for every 1,000 people living there; the World Health Organization (WHO) recommends at least five. India averages 0.8 doctors for every 1,000 citizens; even Italy, which has been badly hit by the coronavirus outbreak, has five times as many doctors per capita.

There is ample reason to fear that if the coronavirus disperses rapidly through a country as densely populated as India—it may already have done so—it could overwhelm the country’s medical infrastructure. Such misgivings are hardly new: Given the hapless quality of public health infrastructure in India, they are in fact understandable. Yet the Indian state somehow seems to be remarkably resilient when confronted with crises. Three compelling examples from the past few decades suggest that the country has an ability to mitigate dire health challenges even though it has displayed a lax attitude toward addressing routine public health needs.

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When the HIV crisis hit the world in the late 1980s, many experts predicted the virus would severely impact India. Yet the National AIDS Control Organization managed to prevent a national epidemic, with infection rates showing a substantial drop in the late 1990s after an initial spike. At least two policy initiatives stemmed the spread of HIV. The government provided free antiretroviral drugs to the afflicted population. It also made significant outreach efforts to the two most vulnerable population groups—gay men and sex workers—despite having laws at the time that made gay sex illegal. India’s relative success in reducing new infections showed that it was able to adopt a crisis plan despite its laws or subpar health care system. Then, in 1994, there was an outbreak of the pneumonic plague in the city of Surat in Gujarat. After a somewhat confused response, the government nevertheless managed to control the plague before it assumed epidemic proportions. Surat’s officials improved trash collection and street cleaning, and put in place strict standards of hygiene in restaurants—practices that have today made it a public health leader in the country.

There is little doubt that routine access to health care for the vast majority of India’s citizenry, especially for the poor, remains abysmal.

More recently, when confronted with the deadly Nipah virus, for which there is no known cure, Indian health authorities acted promptly to limit its dispersion. Following the initial outbreak, local health authorities sent a virus sample for testing to the National Institute of Virology in Pune. They also waived the costs of the tests and promptly imported anti-viral drugs from Australia. Meanwhile, the National Centre for Disease Control coordinated efforts with local, state, and national health authorities, eventually containing what could have been a far deadlier outbreak.

Despite these relatively successful outcomes, there is little doubt that routine access to health care for the vast majority of India’s citizenry, especially for the poor, remains abysmal. A mere 44 percent of the county’s population has some form of health insurance. This is a situation that the government of Prime Minister Narendra Modi hopes to address as it embarks upon ambitious plans to create a national program to give citizens free health care. But the reality is that India’s health care system has long been unequal. While the poor suffer, the country’s rich can afford elite hospitals that are often world-class. Not surprisingly, India has become a hub of global medical tourism.

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The puzzling thing then is that as of March 16, India recorded just 129 confirmed cases of the coronavirus, with two deaths—a tiny fraction of the country’s 1.34 billion population. What explains these low numbers? If one takes the most uncharitable view, it could be argued that the low number of reported cases stems from limited testing of the affected population. In other words, the actual numbers may be far higher. While this is a plausible argument, it needs to be tempered, as India has 52 medical centers that can test for the coronavirus spread across the country, and they have been aggressively carrying out tests on those suspected of having come into contact with the virus.

The question, then, is whether it is possible to argue, based on other evidence, that India may yet ride out this health crisis without being engulfed in the coronavirus.

A range of government actions suggest that containing COVID-19 may not be entirely beyond India’s capabilities. When the first signs of the virus emerged in the country, in early February, Indian authorities moved to drastically limit flights to and from China. They also quarantined in Kerala several returning Indian students who had been studying in Wuhan, the epicenter of the outbreak. The Kerala state government instituted several measures to contain the spread of the coronavirus, for example by rapidly disseminating information, setting up screening centers at ports and airports, and imposing a 28-day quarantine on people it suspected of having come into contact with the virus (when the national government required only 14 days). One errant couple, who with their grown son avoided alerting airport authorities that they had recently been in Italy, traveled to their native village in Kerala. Once the health authorities learned about this lapse, they immediately sequestered the family and traced those they had come into contact with. Obviously, all of India’s states do not have health care systems that are comparable to that of Kerala. Nevertheless, the national government seems to have taken stock of the gravity of the impending crisis and has sought to assist states to cope with it. To that end, 27,000 individuals in five states bordering Nepal have been placed under surveillance. The government is also setting up isolation wards in public hospitals.

The national government has shown vigor in tackling what has every potential to become a widespread calamity.

Selected other states also seem to have set up some effective measures. West Bengal, which has several direct flights to China, moved quickly to disseminate information about the risks and dangers of the virus. It has invoked the colonial-era Epidemic Diseases Act of 1897, which allows for the enforcement of all government advisories related to the outbreak. It has also closed all schools until April 15. The Kolkata Municipal Corporation, in the state’s capital, set up a monitoring committee to track all fliers coming into the city from any affected country; by early March it had effectively sequestered as many as 1,200 individuals whom it deemed to be at risk.

The national government has shown vigor in tackling what has every potential to become a widespread calamity. In late January, the Indo-Tibetan Border Police, a paramilitary force, set up a 600-bed facility on the outskirts of New Delhi. The government has also created another emergency medical center in the neighboring state of Haryana, under the management of the Armed Forces Medical Services. By early March, more than 600,000 visitors to India had been screened and 3,500 samples tested. (Admittedly, screenings are not foolproof, because some individuals may well be asymptomatic.) And in another case of drastic action—with considerable adverse economic consequences—the government announced it was suspending most visas to enter India until April 15, a decision that came shortly after WHO formally declared the coronavirus to represent a pandemic. India then closed its land border with Myanmar and urged citizens to limit all nonessential travel, with the warning that people returning from abroad would face a 14-day quarantine period.

Despite all the efforts that the government has undertaken to contain the likely dispersion of the virus, it is, of course, entirely possible that an escalating spate of infections will take place through community spread. Once that happens, given the cheek by jowl living conditions of India’s cities and towns, the disease can sweep across the country like wildfire. Under those circumstances, India’s creaking health infrastructure could well find itself to be overwhelmed. The question then is whether New Delhi’s actions have bought its people enough time—and whether they will do their part by practicing social distancing and taking personal precautions.

Sumit Ganguly is a columnist for Foreign Policy.

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