Struggling to contain a deadly second wave

India can’t vaccinate its way out of its latest Covid-19 surge

The country is struggling to contain a deadly second wave.

By Jen Kirby

India is facing a deepening Covid-19 crisis a year after it went into one of the world’s strictest lockdowns.

But this time around, authorities are reluctant to reimpose a nationwide stay-at-home order. Add to that a flailing vaccination campaign and the spread of new virus variants, and India’s immediate future looks grim.

For nearly a week, the country has recorded more than 200,000 coronavirus cases daily — one of the highest rates anywhere in the world, though likely still an undercount. A shortage of beds and oxygen is straining health care systems, particularly in cities such as Mumbai and Delhi.

People are using social media in an attempt to crowdsource care and to share reports of people going from hospital to hospital in search of treatment. Daily deaths have also increased, surpassing more than 1,700 on Tuesday, and crematoriums can’t keep up with the number of bodies.

A tangle of factors is likely fueling the surge, which makes it difficult to pinpoint exactly what’s going on. “Many of us are still scratching our heads about this. There’s no concrete evidence,” Manoj Mohanan, associate professor of public policy, economics, and global health at Duke University, told me. “What we do know is a few pieces of the puzzle.”

The puzzle pieces include a decline in cases early in the year and the promise of the vaccination campaign, both of which may have given the public and even officials a false sense of security. On top of that, there’s been a general fatigue with Covid-19 restrictions, which felt particularly burdensome when cases were on the downswing.

People started getting lax about things such as mask-wearing and social distancing. Many started to resume something like normal life, attending weddings and other celebrations.

“There was a sense of relaxation in both public policymakers as well as the general public, and there was a noticeable decline in Covid-appropriate behavior,” Chandrakant Lahariya, a public policy and health systems expert in Delhi, told me.

Mass gatherings have furthered the perception that India has defeated the virus — and likely intensified some of the spread. Millions of pilgrims crowded alongside the Ganges River as part of Kumbh Mela, a major Hindu festival in India and one of the largest religious gatherings in the world.

A year into the pandemic, some Indian states are also holding local elections, which are shaping up to be a political test for Prime Minister Narendra Modi and his Hindu nationalist Bharatiya Janata Party (BJP). Modi and other BJP officials have hosted huge political rallies throughout the campaign, usually with maskless crowds stuffed together. His opposition hasn’t exactly been following Covid-19 protocols, either.

“The public sentiment is of denial, fatigue, and fatalistic surrender,” Bhramar Mukherjee, a biostatistician and epidemiologist at the University of Michigan, told me in an email.

Experts are also concerned about the spread of new variants, though it’s not yet known how these new strains are driving the spike or whether they’re more transmissible or deadlier.

But as Mukherjee put it, the more the virus spreads, the more it changes. And those changes potentially make Covid-19 harder to contain.

The challenge of trying to fight this second wave: Fatigue and frustration

To slow its first Covid-19 wave last March, India imposed one of the most aggressive lockdowns in the world. A year into the pandemic, India is unlikely to pursue that course again. “The massive lockdowns are no longer feasible, and it’s become politically untenable,” Duke’s Mohanan told me. “So it’s just not something they can reasonably do.”

The first lockdown battered the Indian economy, and political leaders likely fear the blowback of more sweeping restrictions. Modi said this week that even states should use lockdowns as the last resort and focus instead on “micro-containment zones.”

But as certain states and cities face an acute crisis, there are few options left to try to stanch the virus spread. In Delhi, where the test-positivity rate is nearly one in four, officials imposed a weeklong shutdown with a curfew from 10 pm to 5 am. Officials said people could face fines if they left their homes.

The state of Maharashtra, where Mumbai is located, has imposed strict measures for 15 days, including a curfew and curbs on all but essential services. “I am not saying a lockdown just now, but strict restrictions,” Maharashtra’s Chief Minister Uddhav Thackeray said at a press conference announcing the changes, the BBC reported.

Even without a full-on lockdown, the new restrictions will create additional economic pain.

A Pew Research Center survey estimates the coronavirus pushed 32 million people in India out of the middle class in 2020, and a second wave threatens to inflict even more damage. This is especially true in areas that are heavily reliant on financial services and hospitality industries — such as Mumbai, where many such businesses are now shuttered because of the Covid-19 rise.

This is something authorities are acutely aware of: “I know bread and butter is important,” Thackeray said at the same press conference, “but saving lives is important.”

India can’t vaccinate its way out of this surge

Starting May 1, anyone over the age of 18 will be eligible to get a vaccination, Modi said this week. But expanding the eligibility doesn’t solve some of India’s other vaccination issues.

India’s vaccination program began with great promise, given the country’s experience with vaccination campaigns and its advantage as one of the major global manufacturers of the doses itself.

The Serum Institute of India was already the largest vaccine manufacturer worldwide, and its production is now essential in the global Covid-19 vaccination effort. It’s contracted to produce billions of doses of the AstraZeneca vaccine for India and the rest of the world.

As it started its own vaccination campaign, India donated supplies of its vaccine to neighboring countries in a major show of vaccine diplomacy. The Serum Institute also contracted with Covax, the multilateral effort to deliver vaccine supplies, to make more than 1 billion vaccine doses.

Many of the world’s poorest countries are dependent on those shipments, which are now delayed due to India’s increased demand. Issues at AstraZeneca plants in Europe also led wealthier countries such as the UK and Canada to make deals with the Serum Institute, and they’re seeing delays in vaccine delivery too.

But India’s own rollout has been sluggish, and as Mukherjee said, India really missed its window of opportunity to speed up vaccinations when case counts were low earlier this year. Just over 120 million vaccine doses have been administered in the country so far. It sounds like a lot, until you consider that the country set the ambitious goal of vaccinating 330 million people by summer. Only about 1 percent of the population is fully vaccinated.

And some parts of India have begun seeing vaccine supplies dry up, forcing them to shutter vaccination sites. The Indian government is now desperately trying to import vaccines to help bolster supplies. The country gave blanket emergency approval to most of the foreign vaccines and is expected to receive about 850 million doses of Russia’s Sputnik V vaccine.

More doses are not a cure-all, though. It’s a lot harder to massively ramp up a vaccination campaign in a country that is already floundering because of a health crisis. The same nurses or technicians deployed to vaccinate people are often the same personnel who need to attend to Covid-19 patients or conduct testing and contract tracing.

That could intensify the coronavirus surge, which could further stall the vaccination campaign, creating a dangerous cycle.

“I am worried that the health care infrastructure now has to take care of tests, hospitalization, and vaccination,” Mukherjee said.

Even if India can find a balance between the Covid-19 emergency and vaccinations, it won’t be able to simply inoculate its way out of this crisis. That will require the same public health measures officials know work: masking, social distancing, avoiding mass gatherings, and so on.

“Everybody knew that there would be a second wave,” Lahariya, the public health expert in India, said. “What they did not know [is] when this wave would come, and how long would it last, and what would be the effect.”

“We are in the second wave now,” he continued. “So it’s time to do all the things which have been done in the past.”